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4 / £; r
OBSTETRICAL TRANSACTIONS.
VOL. XXXII.
SsatTBO Bt muss AXD BON, BABXHOLOIEXW CLOiS.
OBSTETRICAL SOCIETY OP LONDON.
OPPrCERS FOR 1891.
Elkctbd PKBNVA.nr Itk, 1B91.
FtnetDBTT-
TICB-
PBRSTUKNTa.
THBiBURER.
CHAiaUjtN or
TtlE DOARO rOB.
TUKEXAUtKATION
or lUDWtVU.
HOKOUASr
BECBETABIKS.
flOVORAKT
LIBBXBIAS.
SOVOBAST
HBUBUa
or OOCHCIL.
OTHER
UElfBERS
OP OOVHCU.
BLACK. JAMES WATT, M.A., M.D.
fBOULTON, PERCY, M.D.
COKKT, THOS. C. HTEUART. M.D, (Bdiwt).
J HAVES, THOMAS CKAWFOKD, M.A., M.D.
] JO>'K8, EVAN CAberdare).
MEKEDFTH. WM. APPLETON, M.B., CM.
LTAPSON, ALERED JOSEPH, M.B.
REHMAN. G. ERNEST. M.B.
L CMAMPNETS,FBANC18HENEY.M.A.,M.D.
r DOBAN, ALBAN.
I HORROCKS, PETER, M.D.
}. DUNCAN, TnLLlAM, M.D.
OLDHAM, HENllY, M.D. CZV«.(«).
BARNES, ROBERT, M.D. (ZVw/«).
HEWITT. ORAILY, M.D.
HICKS. JOHN BBAi'TON, M.D.. P.H.8.
TILT, EDWAED JOHN, M.D.
PRIESTLEY, WILLIAM O., M.D.
WEST, CHARLES, M.D.
QALABIN, ALFRED LEWIS, M.A., M.D.
I. WELLS, Sia THOS. SPENCER, Bart. {Trustee).
BUrLER-SMYTHE. A. C.
CO.\TE8, FRED. WM., M.D. (Sftliitbiiry).
CtJLLINGWOUTH, CHARLES .lAMES, M.D.
DAK'IN. W. RADFORD, M.D.
DAVSON, N, UOITSTON, M.D.
FREEMAN, HENRY W. (Bath).
GALTON, JOHN H.. MJ).
GERVIS, HENRY, M.D.
HEATH, WILLIAM LENTON, M.D.
JOHNSTON. JOSEPH. M.D.
LEDIARD, HENRY A., M.D. (CarlUle).
M.\RCH. HENRY COLLEY, M.D. CBochUale).
NESHAM. T. C. M.D. (NewcaBtlo-on-Triie).
PHILLIPS, G. R. TURNER.
PHILPOT, JOSEPH HENRY, M.D.
POTTER, JOHN BAPTISTE. M.D.
3PENCER, HERBERT B.. M.D.
LWEBB. HARRY SPEAKMAN (Welwjn).
STANDING COMMITTEES.
BOARD FOR THE EXAMINATION OF MIDWLVES.
ca\iBH.iK. CHAMPNETS.FaANClSnENliY,M.A.,M.D.
BDULTON. rEltCT, M.D.
BOXALL, ROBERT. M.U.
OULLINWWORTH, CHARLES JAMES, MD.
(•BLACK. J. WATT, AJ.A., M.D., PresiJcni.
tx.orFicio.J DORAN. ALBAN. ) „ o
(HORROCKS, PETEB> M.D. J ^'"'- ***'■
LIBRARY COMMITTEE.
tx-oprrcio
CHAMPNErs. FRANCIS HENRY, M.A.,M.I>.
OALABIN, ALFRED LEWIS, M.A., M.D.
HEWITT, GRAILT, M.D.
PHILLIPS, JOHN. M.D.
fBLACK. J. WATT, M.A.. M.D., J^retidmtt.
HERMAN, a. ERNEST, M.B., l^eamrer.
.4 DORAN. ALBAN, } rr q
IlOIiROCKS. PETER. M.D.. J """■ ^^'"''■
DUNCAN, WILLIAM, M.D., Stm. Lib.
PUBLICATION COMMIITEE.
GERTIS. HENRY, M.D.
HERMAN, G. ERNEST, M.B.
HEWITT, GRAILY, M.D.
FLAYi'AIR, WILLIAM S., M.D.
POrrKR, JOHN BAPTISTB, M.D.
WILLIAMS, JOHN, M.D.
fBLACK, J, WATT, M.A., M.D,, PretiJtnt.
CHAMPNEYt*. FRANClaHENBY>M.A.,M.D.,
KZ-OFFICIO. < Ediior.
DOKAN, ALBAN. 5 „ „
(.HORROCKS, PETER, M.D.. j ■"*"• *■*'■
HONORARY LOCAL SECRETARIES.
JowsB, Etan Aberdtw.
Goss, T. BiDUULFH Bath.
Shaepin, Henby W. Bedford.
Corky, THOMA9 C. S., M.D Belfast.
Malins, EswAUD, M.D. BirmingliAW.
FURNER, WlLLOUOHBY . > B^gllton.
SALZMANN, FttEDElllCK WILLIAM ) *
Swathe, Joshi-h Guifpitiis, M.D. Brietol.
Lowe, Oeokge Burton-on-Trent.
RiODEN, Geobge Canterbury.
Lawiienck, a. E. Aust, M.D Clil'ton,
FiTzoEBAiB. Chakiks Eoertok, M.D. Folkestone.
BnAiruwAiTE, James, M.D Leeds.
Wallace, John, M,D. Liverpool,
TaosiFsoN, Joseph Nottinghnin,
Walker, Thomas Jameb, M.D PetcrhorougU.
Waltbhs. James HoPKiNa Eeadiog,
CoATEs, FitEBcidCK William, M.D Salisbury.
WusoK, RoBEiir James St-LeoiiardV
TAVtOB, JoHM W., M.D. Scarborough.
Keehnq, James Huiid, M.D Slieffield.
Bdrd, Edward, M.D., CM Slirew«tiiiry.
Chilub, Cbkistopher, M.D Weymoutli.
Haekis, William John Worthing.
IIabvbv, Robert, M.D Calcutta.
nRABFOOT, Arthur MuDBE, M.B Madras.
Pehhioo, Jaubs, M.D Montreal, Canadn.
ANDBB80N, Uett W., M.D Jamaica.
Takasi, Kanarsiro JapAR.
OBSTETRICAL SOCIETY OF LONDON.
TBCSTfKS OP tBB SOCIETY'S PEOrBRTY.
HcNBV Oldham, M.D.
ROBEBT BlBNEa, M.O.
Sir Tbomas SfGNcER Wells, Uate.
HONORARY FELLOWS.
HBITllill SUBJECT)!.
Ejected
1871 Kbillbb, Aleilikdeo, M.D., F,R.S. Ed., Pljyalciou to tbc
RoyaJ Mntrmity Hospitn,!, L^ciurer on Midwirvry and
DiataacB of Women and Ctuldrtii at Surgeons' lUll,
Ediuburgh ; 21, Qtieeo Blrcct. Edinburgli.
1871 KiDO, Gxouge H., M.D., F.R.C.S.I., Ob*<tetriciil Surgeon
to the Coombe Lying-in Iloipilnl; 30, Merrion ti;|unr«
sonth, DubLin.
1870 West, Chables, M.P., F.K.C.P,, Foreign A»ociatc of
ih« Academy of Medicine of Parin ; 55, Uftrie/ street,
W. Fret. 1877-8.
FOBJIQK atJBJEOTS.
1873 Bahkes, Fokdycb, U.D., Professor of Clinical MidwifeT;
and DieeaseH of 'Women at tbe Bellevue Uospitat
>Iedical College, and Obstetric Pbyiician to tbe Bellevoe
Hoapitsl ; S&, Madieon avenue, New York.
^H
PELLOW3 OP THB ^^^^^^^^^|
^^^H Slecteil ^^^^1
^H 1&63
£li&CM VON F£iUNWALi>, Ci&L, M.O., Fraf«t8or of Midwirery,
^^B
Vienna.
^H 1866
HBGBSBERor.R, Theodor, M,D., k la Maternite, et aux
^^M
Enfant* Trouv^s ; HfipitHl ^es AccouclieinenU, Moscot.
^H^isee
LlSAUE WITCH, J., M.B., Proreasor Emmtus and Physician
^^^^L
to tlie Mnximiliiin Hoopttnl ; Spnekaja, 2, St. Fttera-
^^^^F
burg. Trana. 3.
^H
Pajot, Cir. M.D., late Professor of Midwifery to the Faculty
^^1
of Medi<!iiie, PiuHr.
^H I8A2
ScAKSOMir F. W. TON, M.D., Wiiniburg. ^^^^
^H 1877
Stoltz, Profcsdor, M.D. Naucy, ^^^B
^^^^ 1891
Tabnibr, St^fhane, M.D., ProfeMor of ObBtetrics, Faculty H
^^^^^
de M^decine de Parii. H
^^^^1873
Thohas, T. GATJxtARD, M.D., ProfeBBor of Obstetrics in lh« H
^^^^^
College of Physicians and Surjeuiis ; 296, Fifth H
^^^^h
avenue, New York, H
^^^^^1862
ViBoitow, RuDOLr, M.D., Profeisor of Pathological Ana- H
K
„.....-..,„. ^
H
CORRESPONDING FELLOWS.
^^^^187.3
Mabtin, a. E,, M.D., Berlin, TVaM. I.
^H 1876
BtBiN-, P., M.D., 12!f, Boulevard St. GerL^kain, Paris.
^H
Traw. i.
^H 1676
Cdadwiok, James R., M,A., M.D., Physirian far DUfaae*
^^^^^
of Women, Boatou City Hospital; ClareDdon street,
^^^^v
Hoaion. MassnrlinBetts, U.S.
^■~1877
GoODE!.L, William, A.M., M.D., ProfeBsor of Gynecology
^^^^^
ill tlie Uni verity oF Pennsylflnnin ; 1418, Spruce
^^^^P
street, PbiUdeiphia, PeiiiiHytvania.
B 187«
LnsK, WiitTAU Thomtson, M.D., Profesior of Obstetrica,
^H
Ilellevue Hoiipiint Medical College; New York.
^^ 1877
Stobbr, Horatio K., M.D., Newport, Hhode Island, U.S.A,
ORDINARY fellows:
1891.
Tlio«e iiiirk«l tbiu (*} have paid the Compot'ition Fm in lien ot further
■DOunl lubicrtpliniit.
flw UU«n O.P. uc praAxcd to the atnttt»»t tin; "OriginU Fellan" a( the
Socletv.
Sleeted
1887 AoaiKD, ALBXANnBB Louis, M.D., 10, Blandford street,
Portmaii square, W.
1690 AcKr.Ri.EY, Rioni.BD, M.B., fi.S.Oion., Alexandra House,
Aalifaurton, Devon.
iS8i Adahi, Thomas Rvthkr[>deu, M.D., Stamford Home, 78,
St. Jamea's rond, Croydon.
1S90 Al>Dl»sBLL, AuousTL's W., M.B., C.M.Edin., 30, Asbbun
place, South Kenaingtou, S.W,
1863 All&k, Robert Jokn, L.R.C.P.Ed., The Glen, Sammer
bill, Sydney, New South Wnlcs. [Per Alcxaudcr
Allan, Esq., Glen House, The Ynlley, Scarborough.]
1890 Allax, Thomas E., L.R.C.P. & S.Ed., 7, S&lford t«rrac«,
Tonbridgc.
1873 AJXiDt, Hbnki Makcus. P.B.C.P. Ed., 20, EUgencj'
square, Briglitou.
1SB7 AUBKOSK. RoBEST, B.A., L.R.C.P. & S.£d., 1. Mount place,
Wbitcehapel road, E.
1878 AUDEBsoy, Iterr William, M.D,, 95, Duke street, Kings-
ton, Jamaicn. Tra»». 1. Qon. toe. See.
1875 ANDBBaoN, JouH Font), M.D., O.M., I, BuckUnd crescent,
BeUii* park, N.W. Cwnt^, 1882.
Xl»
rXLLOWB or THK HOLIKTIT.
ISfi€* Akdbbws, IIknry Charles, M.D., II, Addlion tcrrac^
Nolting hill, W. CokmciV, IS82.3.
1859 AKoaRws, J.^mrh, M.D., Eirerleigh, Green hill, HampBtead,
N.W. Cmncil. 18SI.
188B Amnaokbr. Eunbht, M.D., Berlin, 292, Oxrord roftd,
5I«nc heater.
1690 Ansok, Okqkgr Edwahd, M.A., M.D.Cantab., St. Thomas's
HDvpital, 8.E.
IHS-I Appleford, Stephen Herbrrt, L.R.C.P. Lond., 17, Fins-
bnry ctrciia, E.C.
1870 Appleton, Robert Cakuale, The Bur Houie, Beverley.
1884 Applbtos, Tuouab A., 46, Britanniii road. Fulham, 8.W.
1883 Archibald, John, M.D., Wooilhouo* Ehvm, Lough borough .
1871 Arqi.£s, Frank, L.K,G.P. Bi)., Hennon Lodge, Wansleid,
Eases. N.E. Cau/jciV, l88ti-7.
1888 Abmsthono, Jahes, M.B. Edin.. 84, !Rodn«y itreet, Liver-
pool.
1886 Ashe, \VtLLt.(.M Psrct, L.R.C.P. Lond., I17 Bank, Cbiile-
hurst.
O.P. AvKLiKU, Jakb& H., M.D., Coniulting Pliyeiciao to the
Ciiclstn Hwpilal for Women j 1, Upper Wimpole
Btreet, W. Couneit, 1865.66, 1872, 1884. Sm. &«.
1878. Hon. Lib. \ 87 A-6. Vice-Pr««. \S77-S. Board
Exam. Midwiett, 1S"2, \^'b-77. Chairman, 1879-83.
Tram. 'J.
1872 AvUNo. Arthur H. W., 94a, Ore&t Porllnud street, W.
1887 Bailry, Henry KReneRicK, Tlie Holliei, Le« terrace, L««.
S.B.
IS87 Bakbk, Osualu, L.R.C.P.&S. Ed., Surgeon- Major, Indiui
Army, Simla, India.
1880 Balls- Head LET, Walter, M.D., F.B.C.P., 5, Collina street
efl»t, Meiboitrne, Ticloria.
1869* BaNiook, Osokor Oba»villb, M.D., Sui^on to the
Samaritan Free HnipitA] ; 12, Qranville pUct, Porttuaa
tquare, W. CouneU, 1874-6. Tram. 2.
PILLOWS OF THE SOCIITT.
XT
Eleoled
1866* Babboub, a, H. Fbbblamd, M.D. Edin., 24, MetTille street,
Ediobiirgb.
O.P. BiEKBs, RoBBBT, M.D., F.R.C.P., Coniulling Obstetric
Physicinti to St. George's HoBpimli 15, Hurley Mrcct,
Caveadish iqunrc, W. Vice-Prfe. 1859-60. Council,
1861-62, 1867. Tr«M. 1S63-64. Prft. t8e5'66.
Trmt. 32. TrH$tfe.
1878 BiBKF,9, R. S. Kancoubt, M.D., Physician to tie CIipIm*
HoBpital for Women ; 7, Quceu Aniic street, CafcudiBli
Miuare, W. Council, 1H79-81. Board Exam. Mid-
wiv<«, 1880-2. Trant. 2.
1877 Barnes, Thomas Hrkbv, M.D., 105, LnndonTcsd, Crnydon,
186<1 BAHKAOLOceu, Rubkht W. 8., M.D., M. Dulwich roftd,
HeroebiU, 8.\V,
1687 Bahtom, Hbnbt Tiiouas, £3, Harford atreet, E.
1887 Baktom, WiLiiAH BoffiK, L,K.C.P. Lond., Stnunton-oii-
Wjre, near Hereford.
1861* Bahtium, Jonw S., F.K.C.S., Snrgeou to the Bntli General
Hospital 1 13, 6iy street, Bath. Council, 1877-9.
I8W BaBSBTT, JoDy, M.D.,l'rofesaorof Midwifery nt the Queen's
College, Binningham ; 1-14, Hockley bill, Birmingham.
Council, 187-1-6. FiM-Pret. ISSO-2. IVffn#. 3.
Bate, Geokoe Paddock, M.D., 41'^, Berbual On-en road,
N.B, ; and 2, North it mbfrlnnd lloiiHca, King Edward
road, lUckiiey. Covneil, 1882-4.
1687 Ba(;hoabtkeb, Hznuv Sp£LHAN, M.B. Durb.. Saville
plaw, Newcftiile-oa-Tjne.
1671 BiEAOH, Fletcubu, M.B., F.R.C.P., Darenth Asylum, Dart-
ford, Kttit.
1871 Bkadles, AKTiiUB, Park Honse, Dartmouth Park, Forest
biU, S.E.
leSfr BsATTV, William Joiui, LK.C.F. Ed., Stock ton-on -Tees.
1866* BBLcnRR, Hekby, M.D., 28, Cromwell rund, West Brtgbloil.
m
rsLLows or thb society.
1871 Bkll, Robert, \f.I>. Glasg., 29, Lynedoch street, Olaigaw.
1880 Beminoton, Robebt Crewdson, M.B., 59, Osborue Bead.
NewcA8H«>on-Tyne.
1873* Bknxst, Jauss Hbnht, M.D., Mentone. CotiiieiV, 1881*3.
Tratu. I.
188!) Bemsok, MA.TTHEW, M.D.Brux.) 35, Dicconion atreet,
Wigan.
1683 Bbrtolacci, J. Hewbtsok, care ^t' Dr. March, Woodlawn,
Spencrr park, New Wnndawortb, S.W.
1889 Best, William James, 1, Cwnbridge terrace, DoTer.
1887 Beswick, JtoBERT, 161, BiehopBgRte street Witbout, E.G.
1691 Beviile, Frbdehick Wells, L.B.C.F.Lond., The Pin,
Palace rond, Baat Molcaey,
1887 BiDKH, GujLRLBS Waltbh, L.K.C.P.Lond., Laxfield, Fram-
liugliam.
1879 BioQS, J. M.. Hillaide, Child'a liiU, N.W.
1889 BiaaiiQPP, Fhanci3 Robert Bur ant. M.A., M.B.,
B.C.Contnb., Belvedere, Mount Flcaiiiiit, Tiiabiidge
WelU.
1890 Black, George, M.B., B.S.LoDd., 50, CazeDo?e rotd,
Stamford hill, N.
1868* BiAOK, James Watt, M.A., M.D., Obstetric PttyBician to the
Clianiig CrasB Hospital ; 15, Clftrges street, Piccadilly,
W. Couneii, 18;2-4. Vice-Prea. 18«5-6. Chairman,
Board Exam. Midwioea, 1887-90. Pra. 1891.
1861* Blake, Thomas Wiujah, Huretbourne, Bournemoutb,
UanU.
1872 Blanu, GEonGE, Surgeon to the MaccleafleLd Infirmary
Park Green, Macclesfield.
1887 Bluett, Obokqe Maliack, L.H.C.P. Lond., 3, Priory road,
Bedford park, Chiawick.
1883 BoKNEY, William Acau»Tii9, M.D., U5, Beaufort ttreet,
Clielien, S.W.
PCLLOWt or THB SOOIKTV.
xni
EUcted
1866* BOOLTOM, Pebcv, M.D., PhysiciAa to th« S&msriUn Five
Ilospiul, li, Sryinoiir Ntreet, Purtmnn iqiiare, W,
Council. 187ft-80, 18S5. Hon. Lib. 18SG. ffon. See.
18**6.9. Fii:e-Pret. [890-9\. Board Exam. Slidwiwt,
1890-91. Trans. A.
1886 BorsTEAU, Roaissow, M.D,, Snrgeon- Major. Indian Army,
c/o Messrs. H. S. King nud Co.. 45. PnM MnlJ. S.W.
1877 BowKETT, TnouAR Edwahd, 11.^, East In din road, Poplar,
B. Council, 1890.
1884* BoXALL, TtoBEKT, M.D., AMtslnnt Obslelric PlijrsidHQ tu,
and liCctiiTPr on Practical Midwifery at, the Middlesex
noapital; 6, GlinnJns street, Caveadi»li square, W,
Council, I8S8-&0. Board Exam. Midmvet, 1891.
Tram. 10.
18911 Boycott, Abthur Koshak, L.B.C.F. Lond., Cane hill,
Ptirlpy, Surrey.
I6B4 BoTs, Abtbub Henbv, L.R.C.P.Qd., Cliequer Lnvu, St.
Aiban<.
1S86 BBAOBDRr, Hahyby K., 7, Horninglov etrcctj Barton-on-
Tfcnt.
1877 BRA.DLET, Michael McWiluams, M.B., jBrrow-on-Tyn*,
1873 BBAiTnwAiTE, JaU£3. M.P., Obctetric Pliyncian to (be
Leed* General [nlipmary ; L^oturer on Disi>aHe» of
WonwD and Cliildrrn xt itie he^A» ficliool of Medicine [
16. ClareiiduR road. Little Woodhcuse, Leeds. FicC'
Pro. 1677-9. Trans. 4, Hon. Uc. Sec.
1880 BsAKroOT, Abthub Mudbk, M.B., Superintendent of the
Govern mcii I Lying-in Uonpiul, Madran, stiil t'rufestor
of Midwifery and Diacaeea of Women aud Children in
tlie MftdrftR Medical CO'lIfge, Pantlioon rofld, Madras.
Hon. Loc, See.
1887 BxUQBR. Ai>oLPHi;it Bdwabd,M.D. £(1., 16,0rcbsrdBtrcct,
Fortuian iqaare, W.
IS72 BxmowATiiH, Thomas, M.B., Ilarrow-on-the-hill, N.W.
Omncil, 1684.
1868* Bbioos, Hbnxt, M.B., P.B.C.S., UtBodaey at., Liverpool.
TQL. XXXU. 6
FELLOWS or THE SOCllTY.
IB69
1885
1887
1866
IS89
1 876
1889
18fi8
1855
EJeettd
18&A BUIOUT, John Mbabv^v, M.D., Aliraeton, Parle hUl, Forest
hill, S.E. Council, 1873-74.
BnisBAXE, James, M.D., 16, St. John's Wood rond, N.W.
Briscok, Jdhn Freuebick, The LamninB, Eaher, Surrey,
Brodie, FaeD£E.icK Garden, M.6., Oak street, Fakenhnm,
Norfolk.
Bboixie, GeobsbB., M. D., Consulting Piiysician-Accouchear
to Queeu Charlotte's Lying-in Hotpitali 3, Chcstertield
Btreet, Mayfnir, W. Cownci/. 1873-75. Pice-Prea., \SSS.
Brook, William Hbkrv B., M.B.Lood., P.R.C.S., County
HospitB), Lincoln.
BuooEHoirse, Ca^niEs TuBiwa, M.D., 43, Minor roftd,
Brockley, S.E.
Beown, Alpubu, M.A., M.B., CM. Aber., ClaremoDt, Higher
BroughloD, Mftiicliester.
Broytn, Andrew, M.D. St. And., I, Bartholomew road,
Keiitieh town, N.W. Train. 1.
BaowN, D. Dycb, M,D., 29, Seymour street, Portraan
square, W.
1889* Brown, William CABNEorB, M.D. Aber., Penang, China,
1S76 BBUKJEa, Martin, 33a, Giouc^eter place, Portniati squnre,
W.
Bbdnton, /ohn, M.D., M.A., Surgeon to the Royal
Maternity Clinrity ; 21, Euatou ro«d, N.W. Council,
I871-;J. Fice-Prct. IS82'4. Board Exam. Midwivet,
1877-82. TraM. 6.
Buksh, Uahkem, Uvprpool Housf, Balaam ittrfet.FtaiiitAW, E.
1882* BcLLEft, AtiOLET Cecil, M.D., Ojifcrd and Cambridge
Club, Pall Mall, S.W.
1885* BCKNY, J, Bhice, L.RC.P. Ed., Newbury.
1877 Bdechell, Peter Lodwick, M.lt., Delnmcra, Brndwcll-
on-Sea, Soutbminster, S.O., Essex. Cowncil, 1882-4.
Vke.-Pret. 1885-7. Board Exam. Mdwwe»,\^&^.T.
Tran». I.
BiiHU, EuwAftD, M.J)., M.C, Senior Physician to the Salop
Infirmary ; Newport Haute, Shrewsbury. Cauneil,
1886./. Hon. Loe. Set,
1865
1883
1877
FELLOWS OF TUK SOCIETY.
SIX
Elected
1888 BcnTON, Hkbbeiit C^mpbcll, L.R.C.P. Loud., lee Park
Lodge, niackhealh, if.G.
1878 IIcTLiiiuSurTHKfALiiitiirGHAULKSfM.lt.C.P.Ed., 76, Brook
street, Grosvenor square, W. Council, 1889-91.
18(>8 Butt, William Fiibdekick, L.R.C.P. Loiid., 48, Pftrk
aUvel, OroBveiior iquare, W. Conntil, I87I5-78.
1887* BcxTON. DoDter W„ M.D. Load., 82, Mocliioer street,
Can'udisli «t|iisrp, W,
1886 Dtbrs, Joun W., M.D., Pbyfticiaa for Diseasca of Women
to the Rojnl Hoipital, BclfMt) Loner crescent, Bel-
fast
1883 Caldwell, Williah T. D., M.D., 209, Brixton road, S.W.
1887 Cahkhom, Jambb Cjialmeks, M.D., PrafetBor of Midwifery
and DcKBscB of lofancy, McGJll University; 941, Dor-
chenter street, Montreal,
1887 Caueron, Mubdo'CH, M.D. Gins., 7, Newtou lerrace,
Charing Croas, GtaKgov.
1888* Campbell. William Maotie, M.D.Edia., I, Prinees gate
Bnst, Liverpool.
I8«I Cakdlisii, Hkxut, M.D., 6, Barns street, Ayr, N.B.
1886 Cak?bntbk, Akthcb Bkiutowe, .M.A., M.B.Ozou., Wykc-
bam HotiEC, Bedford park, Croydon,
1872 Carter, CHAKr,t;s I[bnrv, M.D., Pliysiciari to tlie Hospital
for Women, Soho Rquare ; 45, Great Cumberlaud place,
Hydft park, W. Council, 1880-2. Trant. 4.
I890 Caktkr, Robert Jambs. M.B. Loud., Lock Hospital, Dean
street, Soho, W.C.
4877 Cakvkh, Eustacr John, 3, Pulham park villaa, Pulhiim,
S.W.
1887 Case, Willuv, 3A, WeatbouiDc road, Araadcl e<iaare, K,
1869 Cabkib, Johk Boyd, M.D., 19, Tyndale place, Isling.
ton, N.
1863 Cayeek, Thomas, Maylield, Aigbarth, Ijiverpool.
1875 Chakfubs, KnwARD, F.R.C.S., J4, North itreet, Kcighley,
Yorksbin.
XX
WLLUWS Of THE SOCIKTY.
1876* CHAUFNiiys, Francis Hbnkt, M.A., M.D.Otan., F.R.C.P.,
Pbysiciiiu-A'ccouclieur to, and Lecturer on Midwifery
zi.St. Barltioloniew's HriBpitHl, GO, Orent Cumberland
place, W. Council, \fim-]. Hon. Lil>. i6^2-S. i7«i.
Sec. I8S4-7. Viw-Pr^t. 1888-1)0. Hoard Exam, Mid-
wtPM, I8H3, l**88.g0; Cfiatrman, 1891. Trana. 16.
185,9 CBA^'C£, Buw&KD JOHK, F.R.CS., Surgeon to the Metro.
poiitan ¥ref Hospital tiTid Citf Orthopiedic Tlonpilnl ;
14, TtiiHell Kqimrs, W.C.
I8B6 Ceapm\m, Charles Willum, M.D., Ti, Fitijohira avenue,
H«rop»teB(i, N.W.
iSfiT* Chaeles, T. Eumondstounb, M.D., Cannea, Fnmce.
CoKKcii 1882-4.
1874
1886
Cha-RLESWOBTH, Jaues, 25, Birch terrace, lUnley, Stafford-
ahire.
1S68<
1890
1883
CaASPSNnE&, AhbhosgE. L., M.D. Durb., 60, Higli ttreet,
Urbridgf.
CniLb, Edwin, "Vernlani," New Maldcu, Kiagston-on-
Tliamei, Surrey.
CuiLDE, Chabi,f.» Pluulev, B.A., L.R.C.P. Loud.. Cnmcleii
Ilouee, KcDt road, Southaea.
Childs, CHKI8T0PHEK, M.A., M.D. Oion., 2, Royal terrHce,
Weytnoulh. Hon. Loc. Sec.
1863* ClusnoLU, Edwin, M.D., Abergcldie, Aaliiield, near Sydney,
New South Wuiea. [Per Meaars, Turner and licu-
dtiBoo, care of Measri. W. Davaon, 121, CanuDD
•Iret-i. B.C.].
CnrrrMtOBK, Thomas Hiwieh, L.R.C.P. Lond,, G&rdeu
llouie, Whcalbampatead, Herts.
CLArHAM, Edwasd, M.D., 29, Liiigfield rund, Wimbledon.
ClaREMost, Claudb Glahkr, Millbrciok Houie, I. Hamp.
Btcfld road, N.W.
Clakks, Reqinald. South Lodge, Lee parlc, Lee, S.E.
C»~AV, CHAttLEb, M.D., Tower Lodge, Poulton-Ie-Pylde,
ItBDCubira.
TELLOWa or TBB SOCIKTr.
tx\
Sleeted
1876 Clat, Georoe LANosroKD, Weil View, 443, Moietey
ruiu], HigligHte, BinniDgliBm.
O.F. CtAT, John, Profresor of Midwifery, Qlieen'e College, Bir-
minghum ; AUnn U»u«p, SteHhoiiup )nne, Birminghim,
Couneil, 1868-69. Vict-Preii. 1872-1.
I8S9 Clemow. ARTiiitR nESRV Wriss, M,D., cm. Edin., 2,
Talgarth ronil. West Keiisingto]], W.
O.F. Cleveukd, William Frederick, M.D.. Slum *iUn,
I!)!), MaidR vnl^ W. Cmnti!, 1863-64. riee-Prti.
1875-77, l88;-[i9- Trant. \.
1881 Closk. James Alex.. M.B.. P.O. Boi 96, Summerlield, St.
Clair Ca., lUinoie, U.S.
1865* CoATKS, Charles, M.D,, PiiyeicifiH to the Baih General
and Roynl United HusjiitnU; 10, Circux, Bath.
1882 CoATEa, Phedbkick William, M.D., St. John street, Salia-
bury. CbwnciV, 1691. Hon. Loc. Stc.
1878 Cockell, Frederick Euoab, Jud., 62, Forest road,
Dalaton, E.
1875 CoPPiN, KicHAKD Ja8. M&itlamd, F.H.C.P. Ed., 98, Earl's
Court roftd, W.
1878 CoFPiv, Thomas Walkrk, 22, Upper Park road, Harer.
•lock hill, N.W.
I87i» Cols, Richard Brverlv, M.D. Jefferson Coll. Philnd.,
218, Post street, San Fmncisco, California, U.S.
1888 Collinh, Edward TEm80^, Canipden House, Oakficid
road, Sclly park, Kirmingkain,
1884 Collins, William Job, M.D., B.S,. B.Sc. Loud,, F.R.C.S.
Eiig., I, Albert trirnce, Olouceater gate, N.W.
1877 CoLMAN, Walter Tawkll, The Poplara, Deddiogtoii,Oxi>ii.
186fi Coombs, Jaubs, M.D., Bedford.
1874 CooPEB, Hkbbert, LR.C.P. Bd., Tburlow Hoiue, Hamp.
Btond, N.W.
L88B CooPEH. IVrsu, L.U.C.P. Load., StainlOD Lodge, filack-
ixatb, ^.U.
xxii
FSLL(]WS OP TOE SOCIETY.
18110 CoPtLAKU, William Hbnsy Laukkncb, M.B.CsnIitl)., &g,
Warwick nimt, Barri Court, S.W.
1888 Corby, Heniiy. B.A., M.I).. 62, Houlb Mall, Cork.
1875* COBDES, ACG., M.D., M.R.C.P., Coosultiiii; Accoucheur to
the " Mincriciirde;" Frivat Uoceiil for Midwifery at llie
Uiiivorsitj of Geueva; l2,RueBenol,Geneva. Trans.l.
\ii&3 CoBMiiu, CuustiAM, 113, Mile Bnd road, E.
li}S8 CoKNisii, Charles Newton, L.K.C.F. Bd., Bushey Ilenth,
H<>rtB,
1S60* CoHRT, Thomas Charles Stbuart, M.D., Senior Surg«oii
la ihc BelfHsi General Diapensarj ; OrmeBu terrnce,
Btlfaal. Couf,dl.\m7. Fict-Prirt. 18S\. Hon. Loc.
See.
1888 Cosy, Isaac Ri&iko, L.R.C.P.Lond., Sliere, GuiLdford.
1875 Cory, Bobkut, M.D., AaBiatant Obstetric Pliysician to St.
'riioniHs'fl Hospital; 73, Lambetli Pnlace road, S.E.
CoufffiV. 1879-8M884.5. Fict- Prci. \m7 -SB. Tram.l.
1886 Cox, JoasvA John, M.D. Ed., St, Bonaii's, Clareudoo road.
Eccles, Manchester,
1869 Cox, HiOHAKi), M.D. St. And., Theale, near Reading.
TVaiM. 1.
1877 Cbawfokd, Jamkc*, M.D.Durh., 4, Iddealeigh MansioDB,
Victoria Btrtet, S.W.
1863 Chease, Jame» Kodbrtson, F.B.C.S. Ed,, 2, Ogle tcrraee.
South Shields.
1881 Cbba&i, James Gidkon, Rectory lodge, Briisted, SeveiioakB.
1863 C&SHtN, Patrick Johk, M.I>„ 4, CfLmden place, Cork.
1876 Cbew, John, Manor House, Highaoi Fwrew, Northim>pton-
abire.
Bd Cbopt, Hdwakd OoTAViua, L.II.C.P. Loud., 8, Clarendon
road, Leeds.
31 Cbonk, Herbeut Gbobge, M.B. Cantab., Kepton, near Bor-
tou-on-Ticnt.
FBLLOWB UV TUX BUCtBTY.
XXUl
BlKttd
1886* Cross, Williak Joseph. H.H^ HorBham, Victoiii, Aut-
tr&lis.
1889 Clorc!!, Edwabi> Thomas, Lee House, Stoke road, Goeport.
1875* CuLLiKowoRTH. CiUKLKs Jamks. M.D., F.R.C. P., Obstetric
Fhyiiciau to, kikI Lecliirer on OUtetric Akdidne at,
St. Thomas's Uoapital i -)(>, Brook street, Groarenor
square. W. Council, 18»3-.^, 1891. Fiet-trH. 1880-8.
Uoard Ezam. Midwivet, lS89.ai. Trans. 7.
1859 CusoEKVEN, i. Brbsbon, Teddiugtoa Hall, Tcddington,
S,W. Council, 1870-72- Trma. 3,
1889* CuBSETJi, JciiiNoiK J.. M.D. Brux., 94. Cbundunwidi.
Bombay.
1885 Dakin, W. KADfOitD, M.D,, Obstetric Fky*iciAD to, aiid
Lecturer on Midwifery at, St, George's Ilotpiul ; 57,
WelUcck titreet, CavendUb s<jiiare, W. Cauneii, I889-
91. Tram. 2.
T888 Dalt, Fkkukhick HENBr, M.D., ISS, Amliurst road,
Hacknejr Downs, N.B. Council, 1877-9. Pict-Pret.
I88S-S. Tram. 2.
1882 Dambrill-Datibs, Wiluau R., Alderley l^dge, Cbesfaire.
1888 Daub, Bobsiit, Singnport, Straits Sclllcmfuta.
1884 Darwik, Geuuoe Hlsby, H.R.C.P., The Cedars, Albert
park, Diilsbury, nenr Maoclieeter.
1689 Daties, Frederick Ukxbt, M.B., CM. Edia.. Tilbur;,
Kssex.
1876 Datibs, Goher. L.R.C.P. Ed., 9, Pembridg« villas, Bays.
water, W.
1884 Daties, Jobx. 91, New North road, N.
1885 Davjks, Wiluam MouBiaTOK, H.D., 55, Gordon square,
W.C.
1877 DaVbow, Suith Houston, M.D.,CAmpden villa, -JOS, Mnida
laie, W. Couacil, 1889-91.
[891 Dawson, Ernest, L.[t..C.F.Load., Th« Mount, Bajnit-
stead, >'.\V.
XXIV
rsuowa or the aociBTV.
itisg
imd
Bhcted
1889 Dawson, Whjjam Edwabd. L.K.Q.C.P. ftL.M., 83, Cbi«.
well »treet, B.C.
1876 Day, Hdmuns Ovebma*!, Assistant Surgeon lo the Ro^rI
Infirmary for Cliildreii and 'Wonieii, Waterloo Bridge
road i 78, Wnterioo road, S,B.
1880 Day, William Hamkes, Surgeon to the City Primjn*,
Norwich ; 3, Snrrey sLri-tt, NorwicL. Trant. I.
Dav, William Henry, M.D.. Physiciau to the Samariwn
Fre« i!o«|iii«l Tur W'onitii mid Cbildreii ; 10, Man-
clieBtcrequare.liV. C»«mci7. 1H7,1-7S. Ficir-i*rM.18M5-6.
Dm S'cEUX, Harolu a., M.D. Brux., tl, CnrlUle Mnueiooa,
Aeliley placo, Victorin 8tr*ct, S. AV-
IS-/ Dewah, Joes, L.R.C.P. Ed., 132, Sloaiie street, S. W.
l8Bd D'MoNTE, DoMisicK A., M.D., Bnndorn, Bombfty.
1887 DoDsoN, Aktrdb Edward, Lll.C.P. mid L.il. Ed.. Win-
dcruivrc villas, Enrlafield, Tooling, S,W,
1879 Dolan, TuoitAs Micir*Ei:, M.D., Horton houee, Halifax.
Donald, Abohibald, M.A., M.U. Edin., 274, Oxford road,
Manchester, Trans. I.
DoUAN', Alban H. 0., r.R.CS., Surgeon to tte SamaritBQ
Free Uuii(>ilai ) 9, Granville pince, Portniau square, W.
Ccuneil, 1B83-5. Hon. Lib. lS81i-7. Hon.Sec. 1888-91.
Trans. 10.
DoiiTY, EuwABU Henkk. M.A., M.B., B.C. Cnutalj., 69,
Bridj^e street, UiimUridge.
DoTASToy, MuwABD Gl>MUNl>, 81, QuecuU crescent,
Haverttoclc hill, N.W.
DoWNES, Denis Sidney, L.K.Q.C.P. I., 55, KeutiBb town
ro«d. N.W.
DOTLE, E. A. Qai^neci, L.K.C.P., Coloniul HuviiitnJ,
Port of Spain, Trinidad.
Dbage, CiiAttLEs, M.D., Hatfield, llerla. Council ISfiM.
Tratu. 1.
1886
rxLLav/a uf tub 80C1sty.
JLXV
EiKied
IWb riuau. Lo\£LU M.A.. M.U., B.S. (Oxon). Burldgli Mead,
Hatfield.
1871 Uiiakk-Bhockman, Kuwahd Forstbii, F.R.C S, L.R.C.P.
LoiiJ.. SurgGOii-Majar: Siiperiiitt>n(!ent V.ye Infiriti«ry,
Madras; Profesior of Physiology and Opbllialmology, '
Mndme He^icnl Cnllege, [Ptr Mpssre. RicliarJdon
Btid Co., Enet India Array Ageacy, 25, fJaffolk street,
Pall Mall, S.W.j
DaAKH, CiiAiiLES Heuey, 204, Brixton hill, S.W.
1S84 DoKE, John C, The Giett, Lcviiham, S.E.
1883 DuKCAN, Alexander Geokoe, M.B., 25, Ambunt puk,
StatnrordbiU, N.B.
O.F. DrKOAN, Jauss, M.B., 8, Henrietta nlreet, Covent gErdcn,
W.C. Comcii, lli73'74.
1888 DiKCAN, Wtlliam, L.1{,C,P.& S.Ed., 17, RedUnd grove,
Bristol.
1882 DCKOAy.WiLLiAU, M.D., Obatetrio PliiyBiclan to, aad Lec-
turer ou Obstetric Medicine at, the Middleicx HaapiliJ ;
fi. Hvley Btreei, W. CokhciV, ltj82-6, lt)tJti-89. Mon.
Hi. 1890-91. Trtms.2.
1871 Kastes, Gkdroe, M.B., F.R.C.S., 3&, GlouceBter place,
Hyde park, W. Council, 1S78-80.
1883 EccLEs, F. KicuiRD, M.D., ProfeftBor uf Physiology,
Weuterii Uuiv*n«iij ; I. Ellwnodplwrc, Quecu'snicuue.
London, Ontario, Canada.
Ehuiaxh, Albkrt, L.R.C.P.Lond.. Bttlerne, near Sooth-
ainpton.
187S EtDKH, Gmirck, M.D., CM., Siirgton lo tite Samaritan
Ilocpiial for Women, Noliingbaui ; 17, Regent street,
Nottingham,
1878 Elleet, Richard, L.R.C.P. Ed., Plymplon, Devor.
1873 EMOELidAXN, Geobou Julius, A.M., M.D., 3003, Locuit
Btreet, St. Louis, Missouri, U.S.
^^^ ixvi
PILLOWS OF THB SOCIKTY. ^^^^^^^B
1 EiectfJ 1
1 1884 Engljuh, Thomas Joenstoh, M.D., 128, FuUmni road, J
^^^^1875
BwABT. John Hknrt, Enstney, Devon«liire place* Eut-
botirne.
I I87fi
FAttK0OHB8, RicHAKD, 40, B«lgrave stree't, GaUnll litstb,
Birmingbani.
^" 1869
Far(J,uhak, William, M.D,, Deputy Surgean-GeDerHl,
Coouoor, NeilgtiprrieB, Mndras.
1861
Kabk, Geo. F., L.R.U.P. EJ., Slade Houae, 175. Keu-
■liDgloti Totii, 8.R. Cotin^l, lS8o. ^^^M
18H2
Pauka», JusEPii, M.D., GaiciEborougb. ^™
1868*
FkoaS, iliouAUU, M.D., Wc»tcombc park, BlAckhentli, 8.K.
188U
Pbgbn, CnAELGa MiLro>, DrvonBlurc Houir, Bnadgn,
Suil'ollc.
188(i
Pennell, Daviu, L.K.Q.C.P.I., 4,St. Aniie'a Villas, Notling
bill, W.
1883
Fkntok, Huau, M.D., 27, George airtct, Uauovcr square,
W. H
Fisher, Fkgdebick Bazlev, L.B.C.P. Lond., West Walk, ^^M
Dorcbeater. ^^^|
!88()
1882
FiTKGKKALu. Chables Egertoh, M.D., Went Terrace, ^^B
Folkestoiie. Hon. Loc. Sec. 1
1«77*
FoNHARTiN, Henky u&, M.D., 1, AncLor Gate terrace, 1
Portsea. 1
^^ 1884
PoitD, AlexaudbH} L.R.C.P.Ed., 9, Beresfoid street, Water- 1
ford. M
^P
FoBD, Jameb, M.D., Eltbam, Kent. ^^H
^^ 188-1
FnuKACUE, RuuKRi Perbiman, 20, Tdliugtou pitrl:, N. ^^H
1 1886
FowLBU, CiiABies OvuEs, M.D., Trevor Ludjjr, 'Tliuruton ^^M
hcfttli, S.W. ^H
1 18/5*
Fkaslk, Angus, M.D., Pbynician and Lecturer on Oinical 1
Medicine lu the Abcrdeeu Ku^aI Jufirmaty ; 232, Uuioo 1
Btrett, Aberdeen. 1
^^ 1888
Fbaber, JaH£3 ALKXJ.NUEK, L.R.C.P. Load., Weetera 1
Ludge, Rumford. ^^^M
FELLOWB op TDB SOCIETY.
xxni
1860
1883
1874-
Sf*ettif
JS67 FiiBSHA!«, HENBr W., 2'1. Circus, Bath. Council, 1S91.
Fby, John Blount, Aehley Lodge, Esher, Surrey.
FuLiK«, KENUt RoxBLROH, M t). CahuIi., 44, Curwo
direct. Maj-fnir, W. Trans. I.
KuaNEH, WuLQUOBBY, F.KX'.S., 2, BruDavick jtlace,
West Brighton, ffon. Lot. See.
Galabin, Ai.rKEU Iikwis, M.A,, M.D,, OhBtetric Phjiician
to, and Lecturer on Midwifery at, Guy'» Hospital ; 49,
Wimpolo Blreci, Cavendish square, W. Council, 1876-
78. Hon. Uh. 1879. ffon. Stc. 1880-3. Viee-Prea.
1884. TVmi. IPS.I-S. Pm. 1889-90. TraM. 12.
Galloway, Au'iuca Wiltoh, L.U.C.P. Loud., 7U> New
North road, N.
Galton, Joun U., M.D., Cliuuani, SylTan road, Up{>er
Norwood, S.E. CuuacU, ltf7-l-6, 1891.
Oanuy, William. Uill Toj), Ceutral liill, Norwood, S.E.
Qaxub, HijMLV CuoKKB., P.K.C.S. Bdin., Maryborougli,
Queensland.
Oakuinkb, Brcvb H. J„ L.R,C.P. Ed,, Qlouceater Uouae,
Barry roaci, Eiwi Dulwicli, S.E.
Garunkk, Joflii'iViKAME.C, llilltburo* terrace. Ilfracombe.
Oabdkbb, William, M.A., M.D., I'rofeawr of Gyniccology,
McGill Uitiv«r(iity ; GyiiEeCKLogiiit to tUe Montreal
General Doapital; 109, Union ivenue, Moulreal,
Canada.
GAENtK, John, I>2, New Hall street, Hirroingham.
Gaktoh, WiixiAU, M,D., P.R.C.8., &&, Bsgot street,
Wavertrer, near LtTcrpool.
Geli, Hsnrv Willixohaii, M.A., M.B.Oxon., 43, Albioa
alTecl, Hyde park, W.
18M» Geevjb, Hbnby, M.D., F.R.C.P., Consulting Obatetrie
PhyaiciaD to St. Thomas'a Hospital ; •Id, Harley street,
CsTendiah square. CounciV, 1864-66, 1»89-!»1. lion.
Stc. 1867-70. FicvPret. 1871-3. Trew. 1878-81.
Pre*. I8S3-4. 3V«m. 8.
1863
1681
1886
1S87
1870
1872
1873
I88g<
XSVUL
rELLUWS OP tHE SOCIBTr.
1666* Gekvis, Fbbueuiok Heudkbourgk, 1, Fellowa rgaU,
HaTerBlock hUl, N.W. CmtncU. 1877-9. Tram. 1.
1884 GiBR, CiiABLKit John, M.U., Wesigate HouBe, Ncwcutlir.
\b7a GiBUiKus, AiiFKED TiioMAB, M.D.t 93, RicbniDDd ro&d,
Dalston, N.E. CounoY, t885.6, 1S88.
1883 OlBBUKB, RoBBHT Al£Xander, M.D., PliysicinTi to tlie
Grottverior Hoapital Tor Women nnd Children ; 29,
Ciidognii place, S.W. Co««c(A 1«89.9U. TroM. l.
\9i7A GlBsoK, JjkMKS EnwAKD, Hilleidc, Went Cowes, IbIb of
Wight.
1869 GitL, William, UK.CP. Loud., II, Kuasell tqiiare, W-C.
1671 GODnAKD, UuoKNB, M.D. Durh., NortL Lyoae, Higtibury
New Park, N. Tram. I.
1871 Godson, Cijcmest, M.D., CM.; 9, Grosvenor street, W.
Cmncil. 187B-7". Hon. See. 1878-81. VicePrct.
1882-4. Board Exam. Miiiwivea, 1877. 1882-86.
Tram. o.
1H68 GoDniN, Anuton, M,D., 28, Brompton cresoeut, BtomptOD,
S.W.
1883 GoiLDoK, John, M.D., '20, WickhamronJ, Brockley, S.E.
E6S9
1889
Goss, TueQKHNA BiODULPU, 1, The Circus, Bath.
Lw:. Sec.
Bon.
GocLLET, CHAHLea Artiiuh, L.R.C.P. Loud., 2, Fiuchlej^
road, N.W.
18S0 Gow, William John, M.U.Loud.,49, Weymouth Btrwt.W.
1689 GhaHam, Authpb. L.R.C.P. & S. Ed.
1B8£ Gkant. Ooiltie, M.D., Queeu Mary's Houbc, laTemeaB.
1890 Gray, Haurv St. Claib, M.l). Glas,, 15, Newton terrace,
GlaBgow.
IS/S Gh-at, Jamks, M.D., 15, Newtou terrace, Glasgow.
1890 Gkbbn, Charles Datid, M.D.Lond., Addiaon House,
Upper Edmonton.
1884 GaEBNK, Waltbu, L.B.C.P. Lyud., Wallingford.
PBLtOni OP THB KOCtBTY.
nh
1887 Qbiimwood, Edwik Climsox, L.R.C.P., 19, St. John'i
wood park, N.W.
1663 OuiFPlTll, U. DK Gobheqobk, 34, 3t. Oeorge'a equnre,
S.W. Trant. 2.
1869
1879*
OuirFiTH, John T., M.D., Tnlfourd floue, Camberwell,
S.R. CounciU l884-(;.
GRimrii, Waltick Sfekckr A>>nRR5io>i, M.D. CAHlnb.,
F.R.C.S., M.R.C.P., Aitiiiant Pliyiician-. Accoucheur
to St. Bartholomeir'n JlospiW ; 114. Harley street, W.
ConncU, IA»fi.8. Board Exam. Hi'itown, 1867-89.
7V«w. 3.
1870
Gbioo, William Ceapmam, M.D., Pliyiicmn to thn In-
|>atifiita. Queen Charlotte's Lying-ia Hoapiul; ABsiRtniit
Obatetric Physician to the Westminster Hospital;
27, Cnwou street, Mnyfair. CouneU^ 187fl-77. Board
Exam. Miilwinei, I87H-79.
886* Gbiusdalk, Thomas Uabihotok, B.A., M.B. Cantab., SO,
Rodney atreet, Liverpool.
6BiHiiDALE,Tao3. F., L.B.C.P. Ed., Gvosulting Sargeon to
the living-in llospitnl ; 29, Rodiiev AlrMi, Liverpool.
CvRMctT, 1861-62. Fiet-Frtt. 1875-76.
Ghippf-h. Wai-TKR, M.B, Cantab., Tlie Poptars, Wallington,
Surrey.
Oeooono, Walteb ATKIS3, Bcrwiclc House, Brondway,
Stratford, K.
6B0TS,Wn.L[AHTllcl{MD, M.D,,S|. Ivea. Iltintingdonsliire.
QB0W9E, WiLLUM, L.K.C.F. Lond., Miirloii, near Ra^by.
Hackkbt, John, M.D. Sl And., Oaklande, Hythe.
Hadaway, Jahkh, L.R.O.P. Bd., Dent.de.Ltoii Villa, Oar-
iingc, near Margate.
Haib, Jahes, M.D., Brinklow, Corcntry.
Halk, Cuaklbs D. B., M.D., 8, Saaaei gardene, Hyde
park, W.
U*Li« Pbbdbbick, 1, Jermyn street, St. Jamca'a, 6.W.
O.P.
-I8S2
1880
1881
1889
18&9
xxt
FBLLOwa or ras societt.
1889 IUll,?krurbiok, M.D.St. Aud., St. Mnrk's Honsf, Leeds.
If>71 Halldwbs, PRsnEBtcK B., R««IbilU B«igAte, Surrey. Cmtn.
eii, 188.5-6. I88ti-S0.
IS$0 Hahes. Georoe ilENRr, P.R.C.S., 2, Qacrnsborough ler-
r&cp, W.
1S87 Hamiltov, ioas, F.K.C.S.Cd., B<>?ctil)tir«t Hoiuc, Sviid.
liucote, Biirloii-(iu-Tieiit.
1883 Hakrfihlu-Jonks, SrosTAOC. M.D.Lond., M.R.C.P., Joint.
Lecturer an Midwifery at, nnJ Phyticiaii-Accourlienr
in cliftrge of Oiit-patiunta to, Sc. Mary's Hospital ; 24,
MonUpi iqusre, W. Couneif, HtitS'J. Tratu. \.
18S0 Harwkv, Ket, Surgeon to the We«t City DiBpentar; ; 4,
WHrdriibe pince, Docinra' nommonR, B.C.
1889 IIaudwick, Akthvh, M.D. Durh., Nevqiifty, Cornwall.
1S86 Hardy, UBS»y L. P., Molly Lodge, Ricbmoud road,
Kingiiton-on<Tham«t.
1889 flA'Rp'eB, Charlks JtiHN, L.R.C.P. Lond., Church end,
Fiiichley, N.
1977 Hahpeb, Gerald S., M.B.Abtr., 40, Cnrzon street, May-
fair, W.
1878 Hahries, Thomas Datiks, F.II.C.S,, Gro»»enor House,
Aberyitwitli, Cardiganaliire.
1B67* Habris, William H., M.O., 7^, Oxford gjinJcns, W.
1861 IIakris, William John, CLureli Houae, Heene, Worthing.
Hon. Luc. See.
1B80* HaWISOU, IlicUABD CitABLTOK, lil, SandringliBin gardeiia,
Baling. W.
1890 Haht. Oavii) Bbrbt, M.D.Edin., 29, Chsrlotte %(\u$.n
Edinburgh.
1886 Hartlkt, Hokaob, L.R.C.P. Ed., Sloof, SulTardalure.
1888 llABTLBt.RBOiNALD, L.R.C.P. Ed., Kirlcgjitp Home, Think.
1880 HAttVBif, John Stbphemsos, 1, Aitvrood road, Cromwell
road, S.W.
FELLOWS OF THE 90C1BTY.
nil
Elected
1865 HAtTEX, RoBBHT, M.D., M, Ohowringhee, Calciiltii.
[Per Hesara. Cuctiran nnd MncplierftOD, 153, Union
street, Aberdeen.] Tram. I. flon. Lot. See.
1B86 HjLRTsr, Sidkey Fred., L.R.C.P.Loni)., 117a, Qaeen's
Gale, S.W.
1888 Haycock, Hesry Erw,^ki). h,R.C.P.R(l., Whilwell. Wdwyn.
1873 Hatks, Thomas CBAWFOiin, M.A, M.l)., F.U.C.P., Lee
turer on Praoiical Midwifery at Ring's CoIlr(|;p;
Obstetric Fhyiiicina to Ki[ig*fl College Hoitpilnl ;
I7j Clai^eo dtrcet, PJEcadillj, W. Gottwil, [b7(i-78.
FietPrtt. 1890-91.
1880 Heath, Wiu-jam Lekton, M.U,, 88a, Cromwell road,
Qaceu'a jjatc. S.W. Council, 1891. Tranx. 1.
1890 HsLMt, T. AsTiiUK, M.D. Bdin., St. Mnry'i Hospital,
Mnnclitater.
. 1867 HzMO&OQco, John Wiuum, M.D., EArtdon, Newcaatle-
on-Tyne.
1876* Hkkuak, Geokob Ersb3T. M.B., F.R.C.P.. Obstetric Phy-
eician to, and Ijectiirer on Mitlwifrry nt, tlie London
Hospital i 20, Harlcy atr««;t, Cavendi^'li equare, W,
Cfiunft/, 1878-79. Hon.I.ih.:»SQ.\. Hon.See.lSB'2-5.
riee-PrtJ. 1SH6-;. Board Exam. Mi,iarlrf». 18fiG-(*S.
Trttu. 1889-91. Traiu. 22.
O.P. Hbwiit. Obailv, M.D., K.R.C.P.. F.R.8. Kd., ConiuUing
Obetttric Physiciau to Uuivcraity College Hvipital;
ae, Berkeley itqimre, W. Hon. Ssc. 18a9.64. Trtat.
iS6i.66. Tice-PrM. 1 867-68. yrM.lSfiSt-yft. Tran8.21.
IK60* HioKS, John Hraxtoh, M.D., F.R.C.P., F.R.S., Pliyiiciaa-
Accoucbeur to, and Lecltirer on Midwifery and Diirases
of Wamrn m, iit. Mitry's Hotpital ; 34, Georgie atrtet,
Mnnover square. Council, 1861.2, 18fi9. Hon. Sfe.
1863-65. yice.Pret. 1866.68. Treat. 1870. Pret.
1871-2. Tra>t«. 37.
1860 Rioos, TiiOHA!! PRKDitRic, M.D., BeMontfield Houae,
Dodley, Worcestershire.
nidi
reLLom nr thk tinriiTr,
EImUH
1836 H0A8, Charles, M.B., CM. Aber., Bsotony llotise, Iliirat
Grc«Ti, riawkhuntl (ilRilwiiy Sintion RoiicrtRbridge).
1886 HonaF.s. Hbrbrkt C[Iamket, L.R.C.P. Land., Wattan.
Hcrta. Traiu. I.
0.f. H0DQR3, RiCHAKD, M.D., F.R.C.S., 3l5. Harewood squnrr.
N.W. TVffiM. 3.
IB87 HoDSON, HENiir Alokukon, L.K.C.P. Erf. Ik L.M., 23,
BniiiRirick iquare, Brighton.
tSSfi HoLUKBTO!!, HBVU-t NsLBoV, L.R.C.F. tond., BmI
MoUscy.
I87S HoUriNns, Ii)DWtii, M.D., 25, Endakigh gardens, N.W.
Council, ISH8.gU.
1880 IToLLOW-M, William Oborob, B.A., M.D. Canlab., Gut
Sussex Jlukpitni, iluBtiiigs.
1859 HOLMAN, COVSTANTINE, M.D., The Barons, Reigste. Surrey.
Council. 1867-69. Vice-Pres. 1870-71.
1880 HowiBALL, OacAB DUNscOMBB, M.D., George Town.Dcmc-
taru, Britiflh GuiHiia.
1864* IIooD, Wdakton Pbtkr, M.D., 11, Seynioiir itreet. PorU
man aqunre, \V.
1872 HOPB, Wlti,rA«, M.D,, Physician to Queen CbBriolle's
Iiyiiig-in Hoipital ; 56, Ciinian street, Mayfair, W.
Council, 1877-9. Board Eram. Mdviites, 1873-4.
IS8I HopKiNB. John, L.R.C.P. Ed., Sa, Cam Let we 11 ntad, S.G.
1883* HoKiiooKS, Pet£r, M.D., F.R.C.P. Loud., Asfeietant Ob-
alftrio Physician to, and Deinoii»trAtcir of Practical
OHttclric* «t, Guy's HoBjiitid ; 'id, Si, Thomng's street,
S.E. Council, 1886-7. Urn. Lib. 1888-9. Hon. Set.
lKa0.9l. Tram. I.
1876 RoftsHAK. GoDFHBY Chaslks, 22, King street, Portman
square, W,
(883 H&sKiN. TnBoPHii.ua, L.R.C.P. Lend,, l86,Amhur«t road,
N.K,
1B83 Hoconiw, Edmund Kiso, L.R.C.P. Bd., 23, High street,
Si('[>ney, B.
FRLLOWB OF THE SOCIBTr.
XXXll)
1884 HouoH, Cai.RLKs Hekrt, Full street, Derby.
1877 Howell, Hobacb Sydney, M.D,, E«st Grove Houae, 18,
Boundary road, St. Joho'a Wood, N.W.
1879 HuBBAftD, Thomas Wblls, Rock Hoiite, Boiightaa Moti-
clieUen, Maid stone.
1885 HCGHES, Bdgar a., L.R.C.P.Loiid., 10, Old Cavendich
■ireet, W.
1689 HuuFHBTS, Chablbs Beyes, L.H.C.P. & S. BcUn., Tfa«
Pnplara, Haramooden, Keat.
l*^* EfCBBT. Jamie»on Botd, M.D. Centab., 43, Castle strtet,
Reading. Councit, 188:~.!>. Tranj. 2.
1878 HcBBAyo, Walteh Edward, 56, Duty New toad, Man-
cbeiler.
1882 HcTTON, Robert Jamis, L.R,C.P.Ed., Carsbalton StapLe-
ton Hall road, Finshnry park, N.
1883 IsMAX, RoiicKT EuwAHn, Gadshill Cottage. Highani, Kent.
1884 Irwin, Johv Arthcr, M.A., M.D., 14, West Twenty-ninth
alrect, New York.
1887 Jacesom, G. E. Corrte, F.B.C,S. Ed., 5, Gt. Marlborough
atreet, W.
1883 Jacksok, Georoe Hekbt, €, Cliff Bridge terrace, Scar-
boroagh.
ISN) Jackson, James, 15. F{ui:itin)*cton street, Bamabnry, N.
1873 Jakiks. William Vobper, L.R.C.P. Ed., IS5, Collins Btreel
East, Melbourne.
'IB72 Jallasd, RunBHT. Uorncaitle, Lincolnihire. Tran*. I.
1890 Jamr9, Ciiable!^ Rbsbv, L.R.C.P.Lnnd., Snrg. Indian
Army (care of MesBfa. Qrindlay and Co., 55, Parlia-
ment street, S.W.).
977 Jaiiiesox, Patrick, M.A., 3, St. Petw'a atreet, PeterJiead,
Aberdecnehire.
B85 Jahibson, Bobbrt Alexavdkr, M.D., ShaDghni. [Per
Meaars. Henry S. King and Co., 05, Cornhill, E.G.]
386 Jamison-, Arthur AHDiiE^r. M.D. Gla».. 18, Lowndea
•Ireet, S.W.
TOi» zzxu. e
xzxiv
FELLOWS OF THE ^^^^^^^^|
ZItcteJ ^^^^H
I883»
JENKIK9, Edward Johnbtone, M.B, Oion., AiiftrnHnn ■
Club. 8yd[if)'. [P«r H. K. Lewifi, 13C, Gover ■trcel, H
W. C] ■
1877
Jfnk3, Edwxhd W., M.D., 84, tsfayetle «cinio, Detroit, ^^H
MictiigitD, U.S. ^^M
1682
Jbnninos, CHAnLEi Eoehtow, F.R.C.S. Fng,, Asiistanl ^^H
SiirKCon to the Norih-West London Hospiial ; l.i, ^^H
Upper Broalc street, Orosvenor square, W. ^^^|
1689
Johns, HtKar Docqlas, L.R.C.P., The DiBpctiBary, GntM- V
M
ISSi
Johnson, Arthdb Jdkes, M.B., 52, Bloor itreet We«t, ^^H
Toronto, Oatario, Cennfla. ^^^|
I88B
JoHJJSON, John Geokoe, L.R.C.P. Loud., Concrete Hoase, ^^H
^^H
Swindon. ^M
^H 1877
Johnson, Samuel, M.D., 5, Hill street, Stokc-upon-Trent. H
^H 1881
Johnston, Jobeph, M.D., 24, Si. Jolm'i Wood park, W-W. H
^^B
Couneit. 1891. 1
^H 1879
Johnston, Wm. Bbecii, M.D., 157, Jatnaics road, Ber* ^
^H
mondsey, S.E.
^H 1868
Jonks, BTAN,Ty-Mawr, Aberdare,G]BitiorgBiislMre. Couneil,
^^B
188fi-8. Vice.^Pret. 1890-91. Hon. loc. See.
^H
Jones, II. Macnauobt&n. M.D., F.R.C.S.I. and Edio.,
^H
141, Hnrley mrcet, Caveiidial] kijuare, \V.
^H 18HI
Jonbs, James Robert, M.B.. 171, Donald atreel, Winnipeg,
^^1
Manitoba, CaTiada.
^H
JoSEs, John, 60, King atreet, Regent siroet, W.
^^^^ 1887
JoNEB. J. TALrouRD, M.B. Land., Rone Bouli, SuutU terrnct,
^^^^H
Eastbourne.
^^^^1886
JoNsa, Lewis, M.D., Onknmd, Balbam, S.W.
^H 1885
Jones, 1*. Svdnet, M.D., 16, College street, llyde park,
^^H
Sydney. [ i'er Meaarit. 1), Joiien and Co., 1, Greaham
^H
buililirgt, Baaiagliall street, B.C.]
^H
JosHS, PuiUP W., Silver elreet, Enfield.
^^^^I8U6
Jokes, William Owen, Tlic Dowm, Bowdon, Maiicbcatcr.
*
FBLL0W8 or THK 80CIBTT.
XXXV
1879 JotTBEBr, Charlss Henry, M.B.Lont!., K.R.C.S. Eng.,
Snrgeou-Major, Dengiil MedJcul Dfpt.,54, CbowringUee,
CalcuttB.
IBTB JCDSOK, TnoMAS Rodbrt, L.R.C.?. Lond., Hayman'a
Grecii, West Derby, LiTcrpooL
1875 JOKBi, AucrsTus, M.B., N. W. Monwled Police, Regina,
N.-W. Territory, Canndn.
1876 Kanb, Na.tiiakiei. H. K., M.D., l.anherne, Kingiiton hilf,
Surrey.
1890 KASTHAcit, Alfrkiio Axtunks, P.HX.S., St. Bartholo-
mtw'a Huspital, E.G.
1884 Kkaies, WiLLiAU CooPBK, L.R.C.P., 2, Tredegar villas,
Eflitt Diilwich rond, S.R.
1S80 Kbbbbii., ALruKL), Flaxton, York.
O.F. Kkklb, Geoiiob Tiiouas, fli. St. PanPa road. High,
bary, N. Council, 1385.
1883 Kkelimo, Jaukh IIukd, M.D., 2(i7,aio*sop road, Shtffit^td.
ffoM. Loc. Sec.
18S0 KliiTU, Skesr. M.B., C.M.Edin., -12, Clitrlea tincl,
Berkeley Square, W.
1674 Kkmi'steu, William HE»HY,M,D.,Oak House, Bridge rood,
BaUersea, S.W.
1886 KcKNKDr, ALraicn Eeimukd, L.R.C.P. 13d., ChesLtrloii
Houu, PUiBtow, K
1879 Keh, Hooit RioiiARi), L.B.C.P. Ed., 1-1, Devouahire Boad,
Balltani, S.W.
1873 KSKB, NoRUAN S., M.D., P.L.8., 42, Orove road, R«genl's
park, N.W.
1877* Kbeshill, Johk Bbdpord, M.R.C.P. Ed., Fairfield, St.
German's, ComwalL
1878 KaoBY, RrsTOXJBE NA8Biiw,i>iiF.K, M.D. Bruswls, L.Med.
Bombay, PliyBician to tbc P«r«ll Diipenury, Bombay (
Girgaum road, Uombny.
O.y. KiALLMAiK, Hesry Waltew, 3, Pfmbridge gardens, Bayn-
•ater. Counnl, l»;g-80.
XXXVl
PrLLOWS OP THZ SOCIETr.
Ktnttd
IttSO EiNGSPORU, Edward, F.R.C.S., Surgeon lo tlie Suiiliury
DispeniKty ; Siinbiiry-on-TUaiueB.
1872* KiscB, Albert. 3, Sutherland gardens, Mnidn »nle, "W.
1876 KsoTT, CiiAaLKB, M.K.C.F. Ed., Lii ViUe, Elm gror*,
Southiea.
Lakr, Geohoi Robert, 79, GlouceaWr creacent, Hyde
park, W.
LJtKSFOBD, CUAHIES P., Suiiiiyside, HornKcr Inne, N.
Lakohohnf, Thomas Giunt, Minioent, S. Australia.
Laholey, Aaron, L.RC.P. EJ., M9, WnUortli road, S.E.
LANXH:3TeK, TIekiikht Hexrt, M.B. Lond., 1, Elm park
gardcDB, Soutti Kenflington, S.W.
Laudek, William. M.D. Edin., 260, Oiforcl road, Man*
chrnter.
Law. William Thomas, M.D. Edin.. 9. Norfolk creecent, W.
Lawrence, Alfred EnwARi) Atisx, M.P., Pbysicinn-
Accoiicheur to the Bristol General KoBpital ; 19,
Eichmond liill, Ciiflun, Briatol. Council. 1BS5.86,
1&S9. Vkc-Prei., \%m-9Q. Hon. Loc. Stc. Trans. I.
Leachman, Albert Warbek, M.D., Fairley, Peterafield,
IlanU.
I86<1* Lediabd, Henrv Ambboee, M.B., 43, Lowther «treet,
Carlialc. ChuncH, ISflO-'JI. Trans. 1.
Lees, Epwin Lkonabjj, M.D., CM. Ed., 2, The ATenue,
RedLand rond. Briatol.
Leisuman, William, M.D., Physician to the Univeraity
Lying-in Hoopital, Kegius Proft'saor of Midwifery in
the UniTersity of Glaagow ; 11, Woodnde crenunt,
GlMgow. Comeil, 1866-68. Viee-Prn. 1869-70.
Trana. I.
Lkwerr, Akthuh. H. N., M.D. Lond., M.R.C.P., Aemlant
Ohfttetric Pliyiioian to the Londun Hospital ; 60.
Winipolc street, W. Council, I8s".8fl. Trtina. C,
Lewis, Bhnest E., L.H.C.P. Lond., Middleaez HoRpitnl ,W.
Lewis, Joun RlOOd Milled, M.D., Deputy-Surgeon General
Markbam J^odgi', Liverpiiot rund, Kiiig«t«ii hill, Surrey
1889
1867*
1887
1883
1886
1886
1887
1875
1878
1887
I860
1885
1890
1877
rELLOWS UF TUK SUCIKTV.
XXSTII
1885 LisiiBD, SvDNSr Robbkt, L.It.C.P. Ed,, 48, Charlott«
street, Hall.
1875 Ljxbmak, Carlo, M.D. Vietina, Prinoipul Surgeon, Trievte
Civil Ho«pital, TrieBic, Austriii. Trans. 1.
1874 LltHQOW, RoBBBT Alexa-Nues Oouqlab, M.D., 27a,
LowudoK street, Belgrave Hqiiare, S.W.
1868 Llewellyn, Evan-, L.R.C.P. Ed., Th« Utnea, Baw road,
E.
1872* Lock, John GRiPPiTn^ ALA., 2, Rock terrjiee, Teabj.
1659 LouuK. TuoMAS ROKBKT. M.D., Bemerton, Torquay.
1890 Low, Habiilu. M.B.CmilAb., Round Hill Villa, Syden-
ham, S.E.
1862 LoTiB, Gbobsk, F.U.C.S., 5, Uorainglow street, finrtoii-oa-
Trent, StAffordsbirc. Couneit, 1867-89. Tram. 2.
Hon. hoc. See.
1890 Lubbock, Eduab AsHLbY, L.R.C.P.Loa(l,, -I, WeatQelil
terrace, Fulhuni road, S.W.
1873 LxJSH. William John Hknrt, M.D.Brux., FyHeld House,
Andofer.
1878* Ltcett, Johx Allan, M.D.,Tbe " Hftllies," Graiselcy, Wol-
verhamptOQ.
1871 McCalldm, Duncan Campbell, K[,D., Eni«ritua Professor,
McGill Unmnitf ; Aa, Uuioo avenue, Montreal, Canada.
Tram. 4.
1890 McCamk, Febdebick John, M.B., C.M.Edin .The Hoipital
for Sick Children, Grent Ormond otreet, W.C.
IS90 McCait, John Dtsart, F.R.C.S., Ivy House, Linfolu road.
East Finchley, IS.
1879 Mackbouoh, Oeorrf. J., M.T>., Chailiam, Ontario, Canadn.
O.F. Mackikdeu, Obapkk, M.D., Connulting Surg«on to the
GainHborougli Pi#prusary; Gaiiisboroiigb, Llncolnilitre.
Otmndl, 187 1-3. TVsim. 2.
1886 HcMnLLKM, Willun, L.K.Q.C.F.I., 3t9A, Brixton road.
S.W.
xxinn
FELLOWfl HI' THE 80CIKTV.
£leeted
1839 Ukvox., llESicr M., M.I>., A, Upper Wimpolc utrctt, W.
Cotneil. i8C3-65, 1884. Vict-Pret. 1872-4. Trsju.
15.
1864 Malcolm, John D., M.B., CM., 2-1, Brynnslon Btrpct, W.
1871 Malins, KuwAiii>, M.O., Obstetric I'lijaiuian to tlie
Geiieml Uoipitd, Uirniiiigbfim ; 8, Old xiuan, Bir-
Tninghnm. Council, 1881-3. Fi>*.PrM, 188J-6. Hon.
Loe. S«e.
I86K* Maiicii, Hknbv Coli-bv, .M.U., 2, WeJt street, Kocli-
iIhIp. Couneii, 18^0.91.
1887 Mahx, LBONA.BO P, L.K.C.P. Loiidi., 19, Upper Berkeleji
ilreet, Portman «qiiare. W.
I860 MABi-nr, Uknky Fhkubrjck, t'lie Nook, PaJsitow, Coruwull.
1862 MAaKioTT, &0BEiir BiroUAKAK, Swsffbam, Norfolk.
1887 Maksii, 0. E, Bulwek, UR.C.P. Ed., Vcntiior House,
Newpori, Mouniotiiliisliire.
189U Maktik, CiiinsTOPiiEH, M.B., C.M.Edin., '6, The Crescent.
BirmiDgtiam.
1873 MAaTiN, Hbnrv Chjuuhnoton, M.B.. CM., II, Bomepi
pUce, Uyilc park, W. *
1887 Mabon, AiiTHUK Hekuy, L.R.C.P.ljond., OakwoocI, Walton-
oii-TIiAiiiee.
1884 Massey, IIuqu Hollaku, 2, North terrace, CambcrwcU,
S.E.
1B84 Ma8Tbb8, Joiim Ai.riiBi), L.R.C.P. Lond., Weatfill Hfluse,
litaok green, W.
1877 MaVMSkll, li. WiuuHHAM, A.M., M.D., Pitl anJ Londun
titrtet, Dunedin, NewZcalaml.
1883 MAKnicE, Oliver Oallki, 76, London atreet, Kcadlng.
Council, I88S-9U.
189il Mat, Chichester Goulu, M.A., M.B. Cnnlob., 13, FiU.
villijini Bqimre, Dublin,
1677 May, Lnvvia Jasiks, liountis T borne, Sereu SUlera road,,
Fiuabury park, N.
ie»A Mavnabu, Kdwaku Charles. L.B.C.P. Ed., 11. Shellons
■iruet, Folkeaioue.
nU.OW» OF THE lOCIBTY.
XXUI
1886
]»83
18?5<
EletteA
1885 Mbllsb, CHaoLBS Bootu, L.R.C.P. Ed., Cowbridgr, Gin.
morgftnsliire.
Mensem,, Zebulon. 31, Shepherd's Biitli rond, W.
Mekkdith, William Ai-pleton, M.B., CM., Surgeon to
the Samnhlnn Free UoHpitsI for Womrn nnd Children ;
fl, Qiie«n Anne utrect, Cavendiili n^iinrp, W. Council,
1886-8. Fite.J'rea. 1891. 7VoM. 2.
Miles. Abijah J., M.D., ProfcMOr of UiitcnseB uf Womeii
sad Ckitdreii tu tlie CinciuuaLi College of Medicine,
Cincinnati, Ohio, U.S.
1676 HiLLH.vN, TubMAS, M.D., M<1r Spadina nventie, Torontii,
Ontario, Ckiih^d.
1880 Mills, Robeht James, M.B., M.C., AJl SainU' green,
Norwich.
1876 MiLsoM, KEcirARt) EIenrt, M.I>., 88, Finchlcy road, Soutli
llRmpiIead, N.W. Council, 1890.
I869» MiKNB, Pembroke R. J, B., M.»., Thctford, Norfolk.
1867 MiTcniiL, RriHERt Nathal, M.D., Chesier Uouse, Wiclc«
liani road, Brocklcy, S.E.
18«8 MooTiioosAWMY, P. S., M.D., F.L.S., Tanjore, Madras
Presidency. Tratia. 1.
1677 Moon, PiiKDeiticK, M.B., Bcilcy house, Greenwich.
1873 Moon, KurnsUT Hgkrv, F.B.C.8., I6U, Norwood road,
West Norwood, S.K.
1859 MoORaEAD,JoUN, M.D., Surgeon to Ibc Weymoutb Infir.
mary nnd Uiapensiiry ; Weymoulli, Uorset.
IdgS MoitoAS, QeoHfiK Johv, L.K.Q.C.P. & L.M., DovaBtau
Uouae, Kinnerley, near Oswestry.
1888 MoHiBOK, Alkxakuum, M.D.Ed., DunnoiUr, 1 1.1, Green
lanes, Stoke Ncwinglun, N.
1890 MooBis. CiuRi.es Arthdr, M.A„ M.B,, B.C.Cantab.,
F.R.C.S., 3(1, Kbnry street, S.W.
186.1 Mouuis, Clarke Kslly, Gordon Lodge. Charlton rond.
Black Ilea ih, S.a
rBLLovrs or tub suuibtv.
1878
1885
1887
O.F.
1888
1887
Elected
1891 MuKTLOCK, CuAULKS, L.R.C.P.Loud., 9, Ladbrvke gordeuo,
W.
1886 MoKTON, SujkUFURTH, M.D. Durham, Wdlcsley tUIas.
Croydou.
1879 MouLLiN, Jahks A. Maksrll, M.A., M.B., AniaUnt
I'byHician to the Hospital Tor WomcD mi<l CLildrcn,
69, Wiiiipole street, CnTcndieli Kquartr, W. Trana. 1.
MoWAT, GKOHOE.49,Bt. Peter street, St. Albana. Tram. I.
Murray, Chaklbs Stokhont, L.R.C.S. nnd L.M. Kd.,
8i, Gloucp«ler place, Portman square, W.
McKBAY, Horace H. C, 470, Hornsey road, N.
ftltisGRAVR, JoiiKsoK TuOMAA. L.S.C.P. Ell, IrUm Villa,
39, Finchleyroail, N.W. Council, 1H59-6U. Tront. I.
Mtbuelton-Gavey, Edwabu Ubbukkt, 64, St. Matthew's
»tre«t, Ipvwiob.
Napikr, a. D. IjEITH, M.I). Aber., 67, GroBTcnot Mreet, W.
Trant. I.
1859 Nbal, Jaues, M.V., Parterre, Sandown, Ulc of Wight.
1882 MEailAU, Tiiuuas CAitucti., M.D., Lecturer on Midwifery
iu tbe Univer»ily of i>urliam College of Mcdiciu« at
Kewcaatle-cn-Tyne ; 12, £Uiaoa place, NtwcaBtle-on-
Tyne. Council, L889-9I.
1859* NtWNAV, William, M.D., Surgeon to the Stamford and
Riitluiid liilirniKry : Bnni Hill Iloufie, Stamford,
tincnliiahire. Council, 1873-75. VUit-Pret. 1676-77.
Traitt, 5.
Newsham, William FlAttnY Chbistopueh, M.A.,
M.B.Cniitalli,, 1, Leiceiter place, Cliftuu, Briatul.
Nicholson, Arthur, M.B. Lund., 98, MoDtpellier road,
BnghtoQ.
1879 NlOHOLaoN, Emilius Rowley, JM.D., 11, Telford atttiue,
Streatham bill, 3.W.
1876 Nix, Edward J.vues, M.D., WA, Great Portland street, W.
Ccuneil. ISSy-SK).
1882 NoiiUA», JouN HOWARD, Liamorc Uouac, Uobbiirn-ou.Tync.
1889
1873
tfEU.on8 or THE SOCIETY.
xli
1883 HvKS, Phiup W. G., L.R.C.P. Lond., MapleBlead, Clirisl.
church road. Botimeinomh.
1884 Oaxbs, Autuuk, M,D., liachamendp, StUTcloy roml, Eaat-
kiurne.
1880 Oaklri, Johk, Holly Hoiiae, Wood's end, Halifm, York-
■hire.
18S6 OOLE, A&TtiDtt Wb3Lby, L.K.C.P. Lend., 90, CAitnon
H«ct, E.C.
1876 003TO,v. Francis, M.D,, Lecturer on Hygiene mnd Medical
Jiiri»[)rui)eiice in the University oT Otngo ; Dunedio,
New Zcfllaad (per iiichard W. K. liuin, 14(), Union
iireet, Aberdeen).
O.F. OuJllAM, Hkkuv. M.D., F.R.C.P., Oonaalling Ohatetric
PbyaiciAu to Guy's llospiul ; -I, Oavcu<ii"h |>lncc,(*ikven-
aiiti nqimtc, W. P'iee-Pr«t. I8fi!J. Vaunetl, 1850,
1865-66. Trtaa. 186K62. Pre*. lSe3-64. Trant. I.
Tnutn.
1888 OLITB&, Frakklis Hbwitt, L.R.C.F. Lond., 2, Kins;iUnd
mad, B.
1889 Oliver, James, M.D., F.R.S. Ediii., IS, Qordon square,
W.C.
I8A4 Ophnshaw, Tbohas Hokrocks, M.Q., M.S.. 21, Govcr
street, W.C.
1869 Obd, George RirE, Sirratliam hill,Siirrcy. Council, I8H1.
1890 Otft, A. AvLMER, M.A., H.B.Oxoii,, 204, Enrl's Court
road, W.
1880 Orion, Chablgs, M.D., Nelsoa pUce. Neweaftlle-ucder-
I-yme, StAffordsbire,
1890 OsBURN, Hakold BiiKUKSs, L.K.C.P., 21, Cedar's toad,
Clspham Conimon, S.W.
1877 OsTKRLOH, pAtL IluuuLPii. M.D. LHpBio ; Drmdeu
1663 OavTALD, JAME3 Wadjjkll Jcpfbibs, M.U., 215, Ken-
niagton road, S.E. Trttnt, 4.
1889* Paoe. IIabut Maruadoks, F.lt.C.8., 4, St. Mnrgarei's
road, Oxford,
ixii
rXLLOVS OP TUE SOCIETY.
JilecleJ
IGUi Falmeu, Johx Iawin, 47, Queeo Aunc ctreet, CcveudUh
ftquatv, W,
1886 Papii.lon.Thomas AlEX*NDEH^ L.R.C.P. Ed., Burley road,
Onkliani.
I877* Pabamork, Kichakd, M.D., 2, Gordon eiquBre, W.C.
1867* PabK8, JoriN, Bnuk House, MaacUester road, Bury, Lauci-
Bliire.
I8d; Parsons, John Inolis, M.D.'Durli., 3. Queen atr«et, May.
fair. W.
ISSQ FAiiaoK9, SiuvBV, 7S, Keiifiingtou PatIc rond, W.
iB8S) Parsons, Tuomas Euwakd, Paddock Hoiwe, RiJgeway,
Wimbledon, S.W.
1805* Patkrson, Jamks. M.D., Haybuni Bank, Particle, GlaBgoi
l8Sli* PjSACHr, William, M.B,, 21-1, Lewisliam High road, S.IS.
1864 PsABttoN, David ltiTCiii&, M.D., 23, Upper Piiillimore
place, Keiiaiiigtan, W.
18/1 Pedleu, GeoiLOE Henry, G, Trevor terrace', ilutland gate,
S.W.
1880 PBi>LEY,TiiOMAsFaANKLm,M.I),,Ilttngoou,Indin. Tram. 1.
1881 Perigal, AitTiixjR, M.D., New BanieE, IlorU.
Iti7l p£R.Kiao, James, M.D., IfiS, Bleury itrcet, Moutreal,
Canada. Ifon. Jmc. Sec.
1H79* PesikaKa, Hokmasji DoaAiiiiAi, 23, Huniby ruw, Boinliay.
1883 Pettu-ek, Epmi'M) Henuit, 3J, Slokc Ncwiiiglou green, N.
187S PUIBBS, llOBEKT b'EATUKUSTONK, M.E.C.?. Kd., 130, Elgiu
Meiiiie, W.
1879 Phillips, Geohoe Uichahu 'rtuNEK, 24, Leinster <qu«re,
Baj-BWHter, W. Council, 1891.
1882 PiiiLLiFs, John, il.A.. M.l>. Canlab., M.R.C.P., AsaUtiuit
Ul>8lctnc Pliyticiau to Kiag'* Cvllcrge Uuspitnl; 71,
Grosvenor atreet, W. Council, 1S87-9. Trotu. d,
1891 PHlLLlfs, W. E. Pjcton, lO.yioaiie Urcet, S.W.
FELLOWS OF THE BOVIKTY.
zliii
1878 Pbilpot, JosKPU Hkkkt.M.D^ 13, South Eaton place, 8.W.
CWnriV, 1891.
1871 FHiLPa, Pqiut Ogorcs, 21, Uuvacll rontl, Kentingtou, W,
1876 Piojtiip, P. KiHKPATniCK, M.D., 5», Abbey road, Si. Jwhn'n
Wood, N.W.
1874 Pioc, TU0MA3, M.D., M.R.C.F., iligb Leam, BeUiiRio,
Kut Oriiiiiteiiil.
1889
1889
PthitoiiN, RiciiABU, L.K.C.P. Lond., &, Cambridge lerrncr,
Dover.
PLATrAiK, Davtd Thomsok. M.D., C.M.Edio., Redwood
Hoiiw, Bromley, Kent,
1864* Pi-A-TFAia, W. S.. M.D., liL.D., P.R.C.P., Pkyiieian.
Accoucliinir to U.I.& R.K. the DucUee* of Bdinliiirgh ;
Professor of Obfllelric Medieiiie in Kiug's College,
and Obstetric PbyMcian to Kinf^'i College llospitnl;
31, George ulreet, Hniioper jtqunre, W. Council, 181)7-
1883-5. Ifon. Librarian, 186S.9. Hon. Sec. 1S7U-
72. Fice-Pret. lH7.'J.r)- Prti. 1879-80. Trans. U.
1880 PocooK, Fueubkicx Ekkest, M.D., The Limeti. St. Miirk'H
rond, Noltiug liill, W.
1883 PococK, Waltek, Gwydyr HouiC, .18, Brixton bill, 8.W.
1B63 PooK, WiLUAX JoiiK, L.K.C.P., 2. Hemingrord roAd, N.
1876 Poi-K, H. CAMrsBl-L. M.P.. F.K.C.S,, IJroomagroTe Villa.
280, Goliibawk road, Shepherd's Bu«h, W.
1888 PoPHAM. Robert Bkooxs, L.R.C.P. & S. Ed., 67, Bartho-
lomew road, Camden road, N.W.
1862 PORTBB, JosEru Fbanois, M.D.. Helmiley, Yorkshire.
1864 PoTTBB, Jons BaPTiste, M.I)„ F.R.C.P., Olmtplric Pliyai-
cian to, and liccturer on Midwirery and DIbcmi?! of
Womcii at, the WvatRiiuvter Hoiiiilfll i 20, George
■trctl, HaiiOTCr iquare, W. CovnfU, 1872-6, lt(90-91.
ffM. it«. l«77-8. TiM-Pi-e*. ]87it-81. TfMs. ]S82'i.
liMtrd Exam. Mu!mw$, I883-'1. Prt*. I8rti.fi.
Tran». \.
1876 Powi>K£LL, JoHy, 16(1, Bustou road, N.W.
sUr
rSLLOWS OP THE SOCIETY.
Eltffini
1884^ Powell, John Jaueb, L.R,C.P. Lond.. Norwood Lodges
Wtyb ridge.
1863 Powell, Jo*iaii T., M.D., 347, City rond, E.C.
1885 Praeoek, Exil Aunold. Naoeimo, firitiah Columbia.
1886 FitiKatZY, IIssrv Soav, L.R.C.P. Lond., 16(1, Anerle;
roBd, Anertey.
1889 pBATT, Oeokqb a., The Willowa, Wiiterloo nmd. Wolrer.
hataptou.
1880* Pkickktt, Marmaduke, M.A.Cantab., M.D., Pliyi>iciftii to
the liJninaritan Hospital i 12. Uevonpoit stneet, Glou-
cester equare, W.
O.F." Pkiestlet, William 0., M.D., LL.D., F.E.C.P., CouaiUtiDg
Obitelric Physician to King's Collrge Hosfiital; 17,
Hertford street, Mftyfnir, W. Council, 18.')9-61, IHfiJ-
6«. Ftce.pre,. IH67-6&. Pre9. IS7J-76. Trant. 6.
|S7fi* QuiitKK, JQSEPH, L.R.C.P. Ed., The Oaklands, Hunter'a
road, Handswortb. BirmlDgltaii).
I8r>l Rasgh, Adolphds A. F., M.D., PhyaiciaQ for DiseaMt of
Women to the German Hoapital ; 7, South street, Fina-
bury 6qQar«, E.G. Council, 1871-3. TVom. 6.
1878 Uawlinos, John Aoaus, M.R.C.P. £d., 4, Northampton
terrace, Svauaea.
1870* Bat, Rdvtabd Revkolds, Dulwich, S.E,
I860* Uaywer, John, M.D., Swalcdale House, Quadrant road
nnrtli, Higbbury New park, N,
1879 Read, Tbomas Lacrekce, II, Peterabnm terrace, Queen 'a
gate. 8.W.
1874 Reek, William, Priory Kouae, 129, Queen's crescent, Haver-
itock liill, N.W,
1890 Beid, Goufrex Forkest, M.U. Dubl., Beibklieiu, Oraogc
Free Stale, Roiilh Africa.
11*79 Eeid, William Luluox, M.D., Profeisor of Midwifery and
Diteasee of Women and Cbildreu, Aiideraoa'* Collage;
Physician to tin; Glasgow Maternity Hospital ; 7, Royal
crcficeiit, QlHB^aw,
rBI-LOWS OP TBK SOCIETY.
zIt
Sleeted
1889 Rehfrt, Lbokakd, M.A., M.D.Caatnb.. 0. Hcrirortl Btrect,
May fair, W.
1889 RxNTOUL, RoHKttT Reii), M.l)., 78, Hiirlington road,
Liverpool,
1875* Key, Ecioexio, M.D., 3fl, Via CavoHr, Turin.
1890 Retsoi-DS, Joum, M.D.Briu,. SC9, Coldliurbour Iniie,
Brixlon, S.W.
tfi^G RicHARUsoK, Thomas AftTHua, 87, London road, Croydon.
1872 RiCHAKlisos. William L., M.D., A.M., Professor of Obs-
tetrics ill HitrTBrtl Uiii»tTBity ; PliysitiMn to tie Boalno
Lying-in lIoBpital ; 225, Conimonwrnltli avenue,
BoatOD, Mattftcliuictts, U.S.
1889 RioiiMosu, TiTouAS, 1j.B.C.F. Ud., 26. Burnbank terrace.
Olaagow.
1688 RlDlNO, WlLUAM Stebr, M.D.Ediii., Buckerell Lodge,
lloniton.
1872 RiODEN, OEOBOt, Sar£«on to the Canterbui-y Dispensary ;
60, Burgale Btreec, Canterbury. Trana, 1. Hon. Loc.
See.
1871 RiouEN. Walter 16. Tburloe place. S.W. CounciV, 1682-3.
Trana. 1.
O.P.* Roberts, David LtotD, H.D,, F.R.C.P., F.R.S. Edin.,
Obstetric Pliyiiciati to ibc MaiiclieBler Kuynl Infirmnry ;
aud Lecturer on Ctiuical Midwifery and the Dieeases of
Women in Owenit College ; 1 1, St. John street, Dfvnna-
gate, MunchcBter. Council, 1868-70, 1880-2. rice.
Free. 1871-2. Trana. 5.
1867* Roberts, Datid W., M.D.. 56, MaucUester street, Han-
phester Bqtiarp. W,
ID RoBtBTS, HuoH JoNii, Sc* Vifw, Penyftrop*, R,S.O., N.
Wal«s.
1883 BoBEKTS, JoHW CoETTOM, L.R.C.P. Ed., A»cnue House,
FeclcliRm rye, S.E.
1874 RoBiBTSos, William Bohwick, M.D., St. Aone'e, Thurlow
park road, Wcat DuUicb, S.K
xW
rELLQWS or THK SOCIBTY.
1890 EoBiNSOS, Abthub Hesby, M.D.Dnrh., The Infirmiry,
Buneroft roiid, S.E.
1887 Robinson, Hugh Shapteh, L.R.C.P. Ed,, 12, North Bridfte
street, Motikwearuioiith, SiiDdcrlsnd.
1884 BoBiM&OM. Luke, M.R.C.P. Load., 217. Geary itireeL, Sun
FranciBco, California.
]89l) RoBSON, A. W. Mato, F.R.CS., HitUry plnco, LpsJi.
1S86 Rob, Abthcr Dimvii.le, B.A , M.B. CHiitnb.. West liill,
Wnnd-worth, S.W.
1876 R-OK, John Wituixotom. M.D., EllcKmere, Sniop.
1874 Roots, William Hewiiy, Canbury llounc, Kingitoo-on-
Tliames.
Ifl74 lloPBH, AUTHUK, Lewishnm lull, HlBClfhenlli, S.E. Couneti,
1B&6.8.
1965* ROFGB, GcoROKj M.P., CoutnltiDg Pliysicinn to the Itnyat
Maternity Charity; Oulton Lodge, AyUiinm. Norfolk.
Council, 1875-77, 1883-5. Vice.Prea. 1879-81, 1883,
Board Exam. Midwivea. 18S0-I, \%m.b. Tram. 10.
lysg R03>, Henry Coopbb, M.D., Penro»c House, linnipatcud,
N.W. Covncil. 1875-77- Tram, 4.
1887 RosENiU, Albert. M.D., Weberganse, l.i, Wienlndcn.
1880 Roaa, David Palmek, M.D., FrGptown, Sierra Leone.
I8S3 RosSRii, Wai,tkk, M.D., I, Wcllenley ^illaa. Croydon.
1884 Ro33iT£B, GnoiioB KRBrcRrcK, M.U., Suri^eou to the
WeRton-Buper-Mare Hoapita.!; Cairo Lodge, Weaton-
anper-Mare.
1885 RoOOKTON, Edhond WlLKlNSOK, M.D., 3;). "WeBtbourne
terrnce, W.
IS84 RoDOHTOH, Walter, L.B,C.P.Load., Cranborn^ Hoaie,
New Barnct.
1S82 RouTir, AiiANU, M.D., B.8., AaniatRnt Obitetric Phyaicinn
to, Riii Teaclier of Practical Obstetrica and Gynaecology
at, Charing Cross Hoapitnl ; Ha, Manchcaler aqiinn,
W. Qounctl, I8S6-!J Irant, 2.
rBLLOVB or THX 80CIBTV.
xMi
Kleeled
O.F.* RonTH.CH&nLEs Hekrt Felix, M.U., ConMtlling Pliynicinn
lollieSntBnritan Free lloapitnl for Wompii ninK'iiildrrn ;
52, Mantdgu nqiwre, W. Counril, 18."j9-61. f'ice-i'rea.
IS74-S. Trant. 13.
1887 BowBOTHAU, IIf.kbkrt C.
1887* Rowi, Arthur WiLTOK, M.D. Dur., I , Cecil stref t, Margnte.
1R8I RovroKTil, ALfKEi) Thomas, Gr«yfi, K«s».
1U86 RttsiiwouTii, FKi.>'K, M.B. Loiid., Ltnigdnlc, Qoldliurat
IcrraCP, South Hanipatead, N.W.
1888 BcsiiwouTn, Norman, Ij.K.C.P. Loud., Be>ecliliel(i, Wnltoii-
on-Thniue*.
1886 RuTHBHrooRD, Henbt Ti{otter. H.A., M.B. Cautab., -JG,
Queen Anne street. Cavendish square, W.
18e6 SaBOIa, Baran V. d«, M.D., Pirectov of Hie Scfaool orMe<]i-
citie, Rio (le JHiiriro ; 3A, Run do Viiconde Mnmngtia^io,
Rio de Jniieiro. Trans. 2.
1883 Saltes, Fkancis JoaEm, L.R.C.P. Ed., 9, tyddon terrace,
Leeds.
1864 Salteb, John H., D'Arcy Houkc, ToLIeahunt D'Arcy, Kel-
rcdoti, Ebbcz.
187^* Salimajim, Frederick William ; Senior Snrgeon to the
Ho«piUl for Women ; 97a, Monipellicrrond, Brlj^litun.
Ccttneil. lfl80-'2. flon. Loc. Sec.
1868* Sams. John Suttoh, St. Pettr'e li«dge, Eltlinm road, Lee,
8,E.
1886 SAKDsasos, Robert, M.B. Oxod., 3'S, Montpellier road,
Brighton,
1872 Samqstes, Ciiarlbs, MS, Lambeth road, S.E.
1870 SaOLjWiluau, M.D., Lyndlhorpe, Boncombp, Bournemoiitb.
18dl Saunders, Fkbdkuick William, M.I)., n.C.Caiitab,, I7t
BMktton garden*, Sontli K*n»ington, S.W.
1872 Sataoe, Tqomas, M.U., Surgeon to ibc Birmingham and
Midland IIospttaL Tor Women; 3;^, Nevhatl street,
Birmiugham. CotineU, 1878-tiO.
xiriii
rexxowa op tbe sociztt.
BUeud
1877 Satobt, Chaklzs Tozkr, M.D., 6, Douglas rond, Canon>
bui7, N. Traiu. \,
1890 ScBACQT, Fit&!iK Fardertck. B.A., M.B.Ciatab., 168,
Earl'i Court road, S.W.
Ilj70 Scott, /oH^, M.D., New street, Snndvicb.
1868 Scott, pATaioK Ccuin, B.A., M.B. CfiDtab., 38, Stioater'a
UiU roAd, BlAckhcAlb, S.£.
1866 S8(jiii:iBA, Jaueh Scott, OB, Lemsa street, Goodman's
fields, B.. niid Crescent House, CasaUod crraccnt.
CMnlaud rond, South Hnckiiey.
1882 SEftJEAXT, David Macbice, M.D., 1, Tbe Terrace, Cam-
brrwell, S.E.
1875 SiTON, Daviii Elphinstgke, M.B., 1 10, Cromvcll road,
8.W. CWrciV, 1884.
I860 Sbweix, Csablzs Dbodie, M.D., 21, Cavendish square,
W., and 13, Fenehurcb street, E.C. CouRcil, i880-'i.
1887 SsiNNON, R. AlEXANUEB, L.11.C.P. Ed.. Croftoti, Orping-
ton, Kent.
O-F. Shihpis, Henuy WrLsoN. P.B.C.S., Surgeon to the Bed-
ford Oeoeral lufirmary, Bedfi^rd. Council, IS7I-3.
Trant. i . Bon. hoc. Stc.
1887 SuAff. Joi<», M.D. Lond., Obstetric Ph^MciBn to the North
West London Hoipital ; S'l, Queen Antie street, Caveti-
diah aquare, W. Tranx. I.
1B67 8ucpUERi>, Fkedsbick, UB.C.P. Ed., 3S, King Hear;'*
road, Primrose hiU, N.W.
1890 SniLLiNGFOBD, Hesey Baetlett, llf, Pecfehftm Rye, S.E.
18S0 Silk, Joriu Fbebehick William, M.D. Loud., 6, Chando*
alreei, W.
1886 SiUUOHS, ForBNEdS, M.B.Edin., Brisbane, Queensland.
1874 SiSclAfK, Alexander DoutL, M.D., ConsHltiiig PhysmaD
to the Boston Lying-in HospiiRl ; 35, Newbury atreet,
Boston, Mnsaacbiieetts, U.S.
rKLl^WS OP THK MOCIETV.
xlix
Elected
1868 SiNCLAitt, William Japp, M.D. Aber., Hoiiornry Pliy»icmri
to like Soutlieni HoAp'ilnt for Woineu ftad CliiLdrcn ant]
Maternity Ilnspilnl. Maiiclieetcr ; nnd I'rofcMor of
Obftletric* and Gynecology, Owena College, Msn-
dieitpr; 2tiH, Oxford ruud, Mnncbts'tr.
1878 SUOHT, Geobge, M.D., .'t, Clifford sirwt, Bond sircer, W.
1881 Sloan, Akchhillij. M.B., 27-2, Bnth ilrcct, Glasgow.
1876 Sloak, Sahcel, M.D., CM., 5, Somerset plnce, Snuclncliiill
street West, Glasgow.
1890 Sloua>-, FKKDEicicK, Uowiirord, 97^, Mootpellier road,
Brigfatoii.
1861 SlthjUT, William Davtisl, 26, CiiverMliain road, Kentiiili
Town, N.W. Couneii, 1H91.
1867 Smith, Hetwood, M.D., 16, Hurley streci, CftvenilinU
nqiinre, W. Council, I8/2-4I. Board Exam. Midtotces,
l«74-76. TraM. fi.
1885 Smith, Howabw LroM. L.K.C.l*,Lond., Buckland Home,
BuckUud Ncwtuu, utBr Durclifntfr.
1890 Smith, llcoii, M.D.Loud., 36, Bow RonO, E.
1875 Sunii. Kiciuni) Thomas, M.B., I'hvMcian t« the Ho»piinl
for Women, Solio equare ; ;j3, llaverstnt^li liill, N.W.
1886 Smith, Samuel Paeboxs, L.K.Q.C.P.I., Park Hyril,
Addi«coni>i4> ronJ, Croydon.
l8Uli Sunn. Stupueh Maberlx, L.R.C.P. Ed., Yarra street,
Geelong, Melbourne. [Per Henry 31. Snaitli, Holly
Lo(Ig«, CItilliiigton, Kiugobridge, Soiitli Devon.]
IB/y Shitu, Wm. Hdcu MosTcoMEbty, UK.C.P.Ed., 2^, London
road. Wert Croydon, Surrey.
1676 Shell, Edmund Guokob Cahrvtbbrs, 10^. Bonner rond,
Violorla park, N.E.
1882 Skell. Geoboe, L.R.C.P. Bd., Fort Canje, Berbic«, B.
Guiaoa.
1889 Solly. Ervest, M.B.Und., F.R.C.8. Kng., 79. Lambeth
Palace road, S.I-:.
I B68 SpaI! iL, BAK!<Aai> B.. 1, Staitwick road, Weit KeuftiugtOD. W.
TOL. XXXJl. d
3
FKLLOWS or THK HUCIETY.
BlecUd
1888 Spencer, Herbert R.. M.D.,B,S. LonJ., Awistant ObaUtric
Phyticiaii to I'liiTersity College IlDspital; 10. MnnB-
field Rtrcet, CaveiiiiUli aquare, W. Council, 1890-91.
Trans. I.
18?6 Spe.vcbh, Lionel Dixon, M.D„ BngsJe-SurgeoB, l,M,S.,
liengn.! EelnliliahrucDl [cnre of Messrs. GniidlBV Rnd Co.,
55, Pnrlinment atr^'et].
mS'J Spoon en, Frederick UENax, M.D., Maillaad Lgtlgc^
Cliipton, N.E.
1876 Spl'bgin, Heubert Brakwiiitb, 8i', Abiiigtou stitcl}
Nortkamplon.
1884 StaNsby, CnAPtRS John, M,D,, 10, Stran^il, Derby.
ISSG StEAVBKsoN, VViLLiAU Ii!uTrABt>, M.D, Cantab,, M.B,C.P.,
15, Mansfield street, W. IWnt. i.
It)84 Stevenson, Esmoj^d Sinclair, F.R.C.S. Kd., Strathdian
House, Rondeboseh, Ca-pe of Gaoi Hape. TroTtt, I .
1877 SxErHENSoN, Wn.LtAM, M.D., Professor of Midwifery,
lIiiireTBily of Aberdeen; 'l^T, Union Street, Aberdeen.
Coancii, 1881-3. Fice.Pres.y 1^87-89. Trana. 1.
1W73 STEWAaT.JAMEs, M.D. ,2, Skinner street, Whitby, Yorkshire.
1875* Stewart, William, F.E.C.r.Ed., Dyrock ColUge, Frcit-
wiclf, near Ayr, N.B.
I68'l SnvEN, Edwabd W. F., M.D., The Manor Lodge, Harrow.
mB4 SriyeMS, DebtkaM II. LrxE, II, KetisiDgtan gardeua
square, W.
1883 Stocks, Fueuebick, 421, Wauditrortli road, S.W.
1866* Stramib, William Heath, M.D., 2, Belaiie aveDue,
EeleiEC park, N.W. Council, 1862-4.
Id7l Stueoes, Mortabue J.. M.D., The Limea. Beckenliaim,
Keut.
1884 SuMDEBLiND, Septiuds, M.D., 155, Gloacffiler road, South
Keusitigtoi), S.W.
1886 SuTCLifFB, AicTHVK Edwin, Cliorllon Ludgc, Stretford
road, Manclieater.
1883* Sdtiieblaku, Heniv, M,A,, M.D. Oxon., M.R.C.P., f,
Riclimond terrace, Wliitehall, S.W.
rBLLOWS OF TBE SOCIETY.
Elected
1^88 ScTTON, John Blakd. P.R.G.8., 48, Queen Ann« atreet,
Cavendish sqiiBTC, W. Trans. 1 .
1859* SwAYSB, Joseph Griffiths, M.D.. PUysician-ApconcIieur
to the DriMol General HoHpiui) ; Karewootl Uouhc,
74, Peinbrokt road, Cliflon, Bristol. C</mcil, 1860-51,
Viee.Pre: 1862.64. Tram. 9, Hm. Loc. See.
1888* SwOBV. llENBV Ceoboe, L.K.Q.C.F. & L.M.. IC, Albion
road, Holloway rond, N.
IVtT, Edwabo Sabink, M.D., 48, Iliglibur; park, N.
Tram. I.
TaIT, E&wakd W., 48, Highbury park, N. Cuuneil, 1886-7.
Tait, Lawbos, F.R.C-S., Surgpoii lo ilie Biritiingliniii nnd
Midland UoBpitai for ^VoIncu -, 7, The CreBcenl, Bif'
nutigliftm. Trant. 12.
Taxaki, Xanaheisu, F.K.C.S., 10, Ki»lu-Konyacbo, Kio-
bashikfl, Tokio, Japnn. Hon. Lee. Stt.
TAJiKEii, John, M.U., F.L..8., PliyRician for DiRcaieH of
Women, to the Fftrriiigdon General DiKpi-nsary; (9,
Queen Anne street, Cavendisti iquaro, W.
Tapsob, Alfkeu Joseph, M.B. Lond , J6, Glouceeter gnr-
dens, Westboume terrace, W. Council, 1862-64.
Fice-Pres. 1891-
Tapson, Josspit Alfbed, Surgeon to the Claphim General
Dispensary ; Hulmwood, Tlie Gro^e, CUpliam common,
9.W. Trans. 1.
Tayleb, Francis T., B.A. Loud., M.B., Claremont villa,
224, Tjewisbam high road, S.E.
Tayloo, John, Knrl'a Cclne, Hulntenit, Bti«.
Tatlob, John W., M.D., D.Sc, Ratbuy Ilou^e, Prince of
Wain terrace, Scarborough. Hen. Loc. Sec.
1690* Taylob, John Wiullm, F.R.C.S., b% BatJi street, Bir-
mingbam.
TitijOK, WttLiAU Cbables Rtebley, M.R.C.P. Edin., M,
Qn«en atreet, iicarborougb.
Thomas, Bbkjamis Wilfbeu, L.R.C.P. Lond., Welwyo.
TflONAB, OeoBOE li. W., Orchard liouae, Teignmoutb.
1883
1879
1871
laso
1871
IS&9
I8«3
1871
1869
n
ie8»
lii
FELLOWS 01' THE S(>CI ItTT.
EUelfd
1887 TuoHAN, William Eduund, L.a.C.P. Ed., Bridgend,
Qlamorgaiiiliirf.
1882 TiioUAs, Hugh, TIr> Grange, Coventry rond, Qirminglinin.
Iti90 i'HOMPso.v.CiURLXS (Ibrbbut, U.A,. M.D. Dubl., 'iX, Ualf-
moon alreet, Mayfnir, W.
1867* TnoMPSoy, Jobepr, Ij.R.C.I'. LohH., I, Oxrord »treet,
Natliiiglinm. Tratu. 1. Hon. Loe. S^e.
1978 TuousoK, Davji), M.1>., 37, t'nttle atrcct, Luton, Bedfonl'
shire.
1874 TuouaoK, Willum Sinclmii. M.D., CM., F.R.C.S.Ed,
I, Palace court, Notling liill gdte, W.
1879 TnoBSTON, J. SxowatEY, M.B., CM., Surgeon to tlie
S.imflritan Free lIoBpiCal for Women and Cliildren, 22,
Porlmari mreel, Poriman Rqufirr. Councii, 1S82-3.
Jlm.Lih. iSfi^-5. Hon. See. 1.H86. FicePnt, 188fi.
Trant. G.
1874 TiCKHLHsT, AuouDTtia RowLANO, SilHietUT HouBp, Prreii-
eey road, St. Lconard'e-oa-Sen.
Ifl73 TicEiiUKST. CiiAHLKS Sage. Petersficld, ITanra.
I86fi TiLLET, Samuel, 6, Down stri-et, Piccadilly, W.
O.F. Tilt,BdwaiidJoun,M.D., CaniultingFliyiieinn-Accoaclieiir
•to the Farriiigdon General Disjiemary; 27, Stjmoiir
■tri-et, Forlrnaii square, W. Council, ))S67-68- Fici'
Pret. 1859-70. Treat. 1«7U2. Pm. 18?3.4.
Trnnit. "■
1883 Tinker, Fredkrick How^ss, P.R.C.P. Ed., Tnlbot House,
Hyd<>, Chcahiiw.
IH87 TlNtEV, Thomas, M.I). Uiirli,, Hiidcgiitd House, Wliiiby.
1679 TiTY, WiiXUU J^UHS, F.R.C.iJ. tid., 3. LsiiBdovn placr.
Clifton, Bristol
1872 T0LOT3CHINO7F, N., M,D., Charkoff, RuMia.
1884 Tbavebs, William, M.D., 2, PiiiUimorc gurdcna, W.
1873 Tbbbtiail, Henry Ebnt.8T. F.R.CS. Ed., M.R.CP.Ed.,
3€, Westbouriic gardeni, GUsguw, W. Trana. 1.
1886 TOCKETT, Waltbh Rboinald, Wfsl Kent General Hospital.
Maidaloiie.
FSUOVTI or TBB KOCIBn.
liii
EUeted
ltiG5* TCHXER, John StoNKT, Stanton Home, HI. Anerlry roAd,
Upper Nonrood.
1881 ToHiu^ PuiNK.is Bahkktt, M.I)., SiAlion Iloapital,
Oibraltnr.
1861 TircKD, JouK James, Junr.. V'.K.C.S., 14, Upp«r Brook
ilreet, W.
1890 Tykhki.1-, Waltkb, L.ll.C.P.IiOiici,, 95, Cromwell road,
S.W.
1874 ViSM, A-LBKBT Joiix, M.D., Olintttric PbyBicinn lo the
MelroiKititKii Free Hospital ; \'2'2, llarlcy Kireet, W,
1873 Vb&lev, KkoinaU) Luuis, I-'.R.C.P. Ed., 2tfB, Uevonkliire
street, PorlUnd pUce, W.
1S79 Waoe, Gcorgs Hekhbiit, Ivy Lailgr, CliiBlelntnit, Kent.
I860 Walks, Thomas CAKKErs, Dawnham Mxrket, Nnrrolk.
1666 Walker, Tiiouas Jambs, ^l.U., Suri;coii lo the Geiirrnt
infinniiry, Peterborough ; 33, Wentgatp, Pctcrborougli.
Vovneit, 1878-8U. Boh. Loe. Sec.
1889 Wallacb. AbbaHak. M.D. Edin,, fi-l. Unrley ilrcct. W.
1870 Wailacb. Kkedkrick, 96, Caaenove road, Upper CUplon,
N. Couneii. 1880.2.
I872* Wallace. Jobs, M.D,, AwiiBtniit-Phyaiciaii to the Iiivcrponl
Lying-iu Hospital ; 1, Gfimbier terrace, Liveq}oul.
n<m. loe. 5«. Council, 1883-5.
1883 WaLIacii, RicuaKU UtJiaANK, M.B.. Cravruhumt, Craven
pMlc, Stamford liiU. N.
1879* Waltr*. William, M.A., M.D., Surgeon lo St. Mnry*.
Iio«pilal, MancbeflUr ; 20, St. John street, Miin-
chesler.
1867* Waltbbb, JAHEa HofKlNs, Surgeon to (lie Royiil Berkihirt
Hoipita] ; 15, Friar Blrt-ct, Reading, Berka. Council,
1B84'6. Tram. 1. Bon. Lac. Stc.
I8"3 WaiTEBS, JOBN, M.B,, Church ttrcet, Reigate, Surrey.
1886 Wake, aBOROE Stephrx, L.R.C.P.liOnd., NpwtownfielJs,
Caralialtou.
liv
TELLOWS OF THE SOCIETY.
Eieeted
IS62 Watkins, Chablbs Stetfabt, 16, King Willumi street,
Sinind, W.C.
Watson, PuRcrvAi Humble, L.E.C.P. Lond., 72, Jestnoiid
road, Newcantle-oa.Tjiie.
Wadgh, Ale\an»kb, L.K.C.P. Lanil., Midsomer-Norloii,
Batli.
Webb, IIabut Sfeakman, New place, Welwyn, Uert*.
Oomcil, 1889-91.
Webbeb, William W., L.R.CP, Ed., Cr<'wkcrrie.
Wedmore, Ernest, M.B. Oanlab., Obstetric Physician to
ibe Itriilol Ruvnl Iiirirmary ; 1 1, Iticbirond lUll,
Ctirtoii.
Weir, ARCinBAtn, M,IJ., St. Miimgljo's, Great Malvern.
Wbllb. Albebt PRiMitosE, M.A., L.R.CP. &S., L.M.,
Bourneville, ijclion) rond, Beckenhnm.
Wklls, Kbank, M.D,, Hftwes aireel, Brooklinc, MnsBacha-
setlB.
Wells, Sir T. Spekckb, Bart., F.R.C.S., Surgeon in Ordi-
DAty to H.M.'a HouBcliold ; CoDBiilliiig Surgeon to the
Bamaritnii Free Hospitnl Tor Women nnd Cliildreii ; 3,
Upper GroBvenor utreet, W. Courtcil, 1859. Fice-
Prei. I8(iS-70, Trans. 5. Truttee.
Wb»t, Gu.vitLEs J,, t. R.C.I*. Loud., Bcnmi nater, EempstiotC
road, Sireatham Common, S.W,
Weston, Joseph TiiEOfnii.ua, L.K.Q.C.P. & L,M., Civil
Surj(eoa, Mergui, Lower Burmali.
WliARnr, RoBBKT, M.D. AbeF., 6, Gordon square, W.C.
WUABTOS, llEKBvTiiOBKTON. M. A. Oxford, 39, Sl.Gforge'a
road, Kilburn, N.W.
WiiEATON, Samoel W., M.D.Lond., 52, The Ctiaae, Clap-
hum common, S.W.
Wheeler, Daxiel, Chelmaford.
Whitcohde, Cuables IIeney, F.R.C.S. Bdin., Westerham,
Kent.
White, Chakles Pehcivai., M.A., M.B., B.C.Caotab.,
144, Slonue street, S.W.
1884
1884
O.F.
I88fi
ISH'^
1876
1887
1876
O.F.
1886
18S8
1886
187E
niLLOWS OF TBB SOCIETY.
Iv
IS90 Whitb, Edwis Feascis, F.E..C.S., 7, DeiiUry road, Putney,
S.W.
1882 Wholey, TttoMA3, M.B. Durh., Winchester House, 50, Old
BroAd street, E.C.
I88S WlCKs, William CAiitN-a, M.B.. Santh View House, Went
patadf, NewcaBUe-ou-'r>-ne.
1887 Wioan.Chablbs Akthur, M.B.Diirli,,P«m8head,Somerget.
1877 WlOMOaB, WittlAM, lai, luveroeas Irrrace, ilyde pnrk, W.
1883 Wilkinson, Thomas Marshall, F.R.C.S. Hd., Surgeon to
ibe Lincoln County Iloapil&t ; 7, Linditm road, Lincolu.
1879 WiLLANS, WiLUAM Blunubll, F.H.C.P. Ed., Much Had-
Imtn, Ilcru.
I87U WiLLBTT, CuAHL£s Vbbuall, 3, Soutbdown road, Shore-
hnm, Sussex.
1889 Williams. Abthlii Hevry, M.A., M.B., B.C. CRutab., 79,
Ijondnu road, St. lieonard'a-on-Sea.
1887 WiLUAUs. Chaules Rdbsbt, M.S., C.M.Ed., 15, Iraaboe
lerratre, Asbby-de-U-Zouch.
1872 Williams, John, M,D., F.R.C.P., Phyniciau-Accuucliciir to
Il.S.ll. Princess Beatrice, Priuccsa Henry of Baltcu-
bcrg ; ProfcBJor of Midwifery in University College,
London, ajid OkMetric PtiyaicJaii to University College
Iloapitul ; 63, Brook street, Grosvenor square, W.
tWnciV, 1H".J-;(J. Hon. See. 1877-9. f'ice-Prca. lSm.2.
Bounl Exam. Miduiivei, 1881-^; OAairmmi, 1884-fi.
Pm. 1887-8. Trcuu. 12.
1890 WiLUAMs, Rroisalii Mdi:io, H.D.Loiid., 95. St, Mark's
rood, N. KeneingtoD, W.
1881 WiLLin, Jt<UA.\, M.R.O.P. £d., 6-], Sutherland avenue,
Msidii vale, W.
1860 Wilson, HoBEai James, F.R.C.P. Ed., 7, Warrior sqoarc,
St. Leonard's-on'Sea, Suasei. Hon. Loc. See. Viet-
Pnt. 1878.80.
WiXTEBSorroM, Artudu Tuouas, L.R.C.P. Kd,, Lark hill,
Swiiilou, MaticliMlrr.
Ivi
FELLOWS or TUK BOGIKTT.
EUcled
1877 Wi)iTLK, Hknks, M.B., Kingtdawii , Church row), Forest
M11.S.E.
(887 WiTfiEHs, Robert, Lawrence, Olago, New ZeRlnnd.
IQyy WooDWAKD, G. i'. M., M.D., 137. Urerpaol etreet, Sydney,
New South Wftlea.
1890 WoBKtJM, Georoe ?oeteb, 6, College terrace, Bel«i(* p«rli,
N.W.
O.P. WoRsUir, J. Lvc&a, Mauor llou»e, lUvcrhcad, SeTeuonki,
Kent. 0)unci7, 1875-77. TiM-i'i-.M. l(*h3-5. Tram.i.
1H81 WoKTHINCTOIC, QtiOBOF. i'tK'CH JK^K1N;GS, M.K.Q.C.P.,
Jlighdcii, Sidcup.
187<i WoBTS, Edwim, 6, Trinity 5trtet, Colcl«Bter.
1887 Wright, Ciiables James, Surgeon to the llnnpUol for
Women and Cliiidreii, Li^rds; Profcaaor dI" Midwifery
to tlie Yorkshire College ; Lyntau Villa, Virginia road,
Leeds.
IBBB* WTAiT-8MiTii,FBAKR,.\l.l{.,b.C.Canlab., Britiali HotpiUl.
Bueaoa AyrcB.
1889 WxHTGu, A»D»EW Ellis, L.B.C,r. Lund., SQ, Upper
Burkekv street, Portmoii squnrc, W.
1871 Yarrow,, Gbuiioe Buoeke, M.l)., Oakley Huuse, 317) City
roAd, E.G. CoanQil, 1S81-:j.
1882* Yoi'Ku, Cii-iKLKa Gkovb, M.D., New Amsterdam, Bcrbice,
BriLisSi Ouinaa.
CONTENTS.
PASS
List of OfBcere for 1891 .
V
List of Presidents . . . .
. vit
LUt of E«ferees of Papers foi- 1891
. Tiii
Slandiog Oommitteea
ix
List of B.oaonury Local S«cre(ariea
X
Tmst^ee [>f tho Societj'a Property
xi
List of Honorary aud Correaiwnding Follows
si-zii
List of Ordinary Felluvra
. Tiii
Coatvnts ....
. Irii
List of PlaUa and Woodoota
. Ixiii
AdreriisemeaL ....
. in
Hon* of Attendfcjici! at liibrory .
. llT
JsnoBiy 8th. 1890—
Rapidly f&tikl CerubraJ Hffimoirliiige oocurrin^ in »
Case of Pregnancy compUcatod with Moltiplo
Fibroids, akonn by Dr. William DrxcAN
Uanvlmivycr'e Trnnefusion Ai)|Mi.rattte, aliown by
l>r. Uatthetcb Dokcjik
Or&riaa Cyst, partly Dermoid, sliown by Dr. 0. H.
GlBTEB .....
Two Dermoid Oyats from tbu mhhc puticnt, ahown by
Dr. 0. H. UAKTEa ....
Lipoma removed from L«fb LabLum Maj'us of u
iroman ugod forty, shown by Dr. 0. H. Oabtbb .
I. Should Pregnancy be terminated prematurely in
Oaaeaof PhtbieiaP By William Duscan, M.D. .
IT. Tito Cues of Puerperal Eclampsia, eBpecially illuB>
mting the Tempernturo and Urine in iLv Di««uo.
By G. EfcMKHT Hksuan, M,B., P.B.O.P..
17
February 5th, 1890—
Annaal Mooting
Double PyuSAlpioi, shown by Dr. C. H. Cabtcb
VOL. XXXU. t
iTJii
OONTSNTB.
Oyatio DiB«aae of the Oliorioii, shown by Dr. Auer
LAWKENce . . .64
Cystic DiBdase (Hydatirorm Degeneration) of the
ChoFion. shovm by Dr. John PaiiLrpB . . 65
T^tenta s.ad Appendages of an Infant; Hte^morrha^
from the Uteiine Mucous Membi-aue, KbowD I>j
Mr. 0. H. James . . . .66
DturDS with Placunla Frffivia. shown by Dr. A. H.
BOBlBsON (communicated by Dr. Cui.LlNawo&lB) 67
ni. Urelhral Diverticula. By Amakd Routh, M.D. 69
AhduuJ Meeting: The Audited Report of tLe Tr«a-
BDMr [Dr. Hermak) . ■ . *2. 8S
Report of the Hoaaraj'y Librarian (Dr. BOB-
bocks) . . . ,82
■ Heport of the Gli&iriuan ol' tbe Boaj'd for the
Erumination of Midwivce ^Dr J, Watt Black) 82, Si
• Alteration in the Laws: Cap. V— Of the Con-
tribntions of FellowB . .84
— Election of OfBcers and Council for the yeitr 1880 85
Address of the PreBident [Dr. Qaj.abim) , 86
March 5th. 1890-
Altemtion of Laws ; Ghftptet- SIX — Of thu Socicty'i
Property ..... ]06
Chapter VllI— Of the Trustees . . 106
Confirmation of the Action of the Council respecting
tbe L«aBe .....
Bcpart of Comaiittee on Dr. Robinson's Specini>eii of
Plucentn PrBvio, ....
IV. Tbe Change in Si£<> of th« Cheat and Abdomen
dnring the Ljing-in Period, and the Effect of the
Binder upon them. By G. EkHKBT Hebman,
M,B.Lond.. F.II.C.P. ....
V. Apoplexy of the Orary; Cyatio Dilutation withont
Hupture. By ALBAif Dokan, P.B.C.S. .
April 2nd. 1«M—
Living Female Child with Three Lover Limbs. flLown
by Dr. Godson ....
Three Cases of Cougenitjil Diaphragmatic Hernia,
ehownby Dr. HjeBBEBTlLSpEHCEB . . 132
I
^^^^^^^^^^^^H ^^^^^
^1
^^^^^^^^^^^ ' PA3B ^^^1
^^^^^^ Case of CcntrnI Ohoroido-retinitie (H<cui'ring ultci-
^^H
^^^^^^L Iiaboiir and PoEit-]>axt»m Htf<morrh&ge, ihown by
^^M
.^^^^V Dr. H.. MAdTACOHTOX JOKXS .
^H
^^H^ UtrruB removed by Porro's Opfriitiun, shown by Dr.
^^H
'^^H CorJ.TKOWOBTH ....
^H
^^^1 Fuitua uuil PlucantA from a Caee of Extra-uterine
^^H
^^H GeatatioD. eliawD by Dr. GoLLtNawoBTU
135 ^H
^^^1 Ouioeroua Uteri removeiS by ViLginuJ Hystorectomy,
^^H
^^H Bbutrnby Dr. ODLLiMdvroBTE .
^H
^^H I>ifiea«ed Ovaries and Tubes, abown by Dr. C. H.
^^H
^^H Cabtek .....
136 ^H
^^^1 Thr^c Specimens of Cot-vit Ut^ri removed foi* Molig-
^^H
^^^1 nant Diseasi^ ahown by Dr. LEWERa
^^M
^^H Cue of Ca&cor of upper part of Cervix extending
^^H
^^^f into Body of tJterua. shown by Dr. Herman
137 ^H
^^H Surcouatouit Utems removed by Vaginal HyBt«reo-
^^H
^^^ tomy, Bbovm by Dr. Dakin
13» ^H
^ VI. Four C'aAett of Yagiuiil Hyateiei^tuujy. By C. J.
^^H
^^L OOLLIKOWOBTH, M.D., F.R.C.P.
141 ^H
f Ihy 7Ui. 1890-
H
L Ct«niB abowing the effects of u Guugrimoaa Fibroid,
^H
1 thown by Mr. J. Bhi.VD Sotton
^^M
^^K AxiB'prcHsnt^ Binder fur uae during Ltkboar, aboira
^^H
^^M by Dr. Atma&d ....
^H
^^V Adjouraed DebatL- ou Dr.CcLLiKOWQKTH'e paper on
^^H
^^^^^_ FoiU' Caaos of Vaginal Hyaturectotny
174 ^H
r Jane Itb, 1890—
H
■ Glands uf tbo Fullopiaa Tube, ahoim by Mr. J,
^H
^^^ BtJkVJ* Brjnov ....
^H
^^H ApopUu:lic Oviiin. shown by Dr. Auakd Rodth
194 ^H
^^^B Dt«ra« and Adherent Placenta from Puticut dying of
^^H
^^^^^_ Poat-pnrttim UieiaorrbBge. shovn by Dr. Juhn
^^1
^^^^B PuiLLipa .....
^H
^^^^^^ SpeciinenB from a Case of Pnnilvnt Seai1<^ EndO'
^^H
^^H Dtctritix. shown by Dr. Ub.buak
^H
^^H Caretnoraa of the Ovary, ahowa by Dr. Oullimo-
^^H
^^^^—^ KOBIR .....
^H
CONTENTS.
PAGB
Vli. Siseeotion of u Fcetue, the Babjaot of Betroficxion,
Ectopia yiacermn, etc.. with Remarks on the
Frequent Aesociation of tbeae Abnorm&titieB, and
ita CauBe. By W. B. Dakis, M.D. . 800
Tni. Case of Spnrioua Pregniuit^y simuUtiug Sctopi« Oot-
tation. By E. Sincljlie Stevemsos . 216
rX. Pevcr in ChiIiSlM>d. Pui-t I, — General Hygieae and
AntisepsiB. By Eobeat BoxAiii., M.D. . . 219
July 3nd, 1890-
Docidua V«ra and Refleia from a veiy Early Alwr.
tii>a, shown hy Dr. HebhAH . . ■ S72
Foetus, Plaeentn, U^mbranca, and Fallopian Tube,
frotn a Caae of Ruptured Tubal GoatatioD. com-
plicated by a larg« Has ma to- salpinx on the oppo-
utte side, shonn by Dr. Cdllimqtcobtb . . 273
Foroi- in Childbed. Part L — GGii«ral Hygiene and
Antisepaia {continued). ByBoBEsr Boxaxl, U.D. 275
October 2nd, 1890—
Vole of Oondi^l«i]c« on the deatb of Dr. J. Matthews
Duncan ..... S06
Right Ovary and Tube distended with Blood, sliown
hy I>r. WniiAM Dmoiu .806
nterine Appendages tlie sabject of Tuberanlar
Deposite, eliown by Dr. Williau DrifCAN . SOS
Uterus with Primary Camcn- of the Body, estiifated
per vaijinain, ahuwu by Dr. Wuj.iam Duncan , 306
DelbaBlaillti'a. Speculum iV glisgieree, shuwn by Ur.
Albas Dobah .307
Tubal gestation removed before Rapture, shown by
Dr, Hbbmah ..... 307
Pelvic orgiinii of a Pationt dying from Injection of
Acid Nitrate of Mei-cui'y into tlie Tagina to pcudue*
Abortion, shown by Br. John Phililifs . . 308
X. Cas« of Symmetrical ErjBipelas, followed by Prema.
turu Labour; SuIutupBia on the niaetet-nth day
post-partum ; Twenty.^'jght ParoiysniB; no Renal
Disease ; Recovery. B; JamiE80:4 B. QuBRV, Ai.D. 309
XI. Four Casea of Pregnancy with Bright's Disease. By
0. Bbkebt Hekman. M.B., F.R.C.P. . 880
COBTEHW.
Id
PAOS
NoromW 5th, 1890-
Cm« of Tubal Abortion, Bhowo hj Mr, J. Bland
Sutton . .342
Suppm-ating Dermoid Ojat, ahown by Dr. William
Duncan .346
Ovo-rf and Vuhe ynth Pupilloma, shows, hy Dr.
William Ddmcan .... 346
Case of AcephiilouB Acardiac Twin, shown hj Dr.
AjJAND ROCTH .... $47
Fonr Cues ol PreguHJicy with Brighl'e Disease
(canttnned). By G. Eknest HBBHAir, M.B.,
FJt.C.P. . .349
XH. On Plugging Ihd Uk^niB in Suvero Ciisee of Post.
partum H^EUorrhage, wtUi Notoe of a Successful
Cue. By Arthur H. N. Lbwbks, M.D. . 356
December 3rd, 1890.
Statement by the Preaident (Dr. Galabin) rcHpooting
the Action of the Coaacil with re^rd to the pro-
posed Biil for the Eegifltration of Midwivea
Polypoid Myoma of the Uterus, shown hy Dr. AUST
laWBSNCB . . . . .
Votical OaJcnli, shown by Dr. AC8T Lawbbkoe
Ca«t of a lai'ge Vesical Calculus, shown by Dr. Auet
Lawbbncb . . . , ,
Calcut) from a Case wf Prolapse of th« Uterus and
Bladder, shown by Dr. Pekct Bodltox .
Fcetua, the suhject of Atresia. Ani Veaicalis, shown by
Dr. Dakis ....
FapiUomatons Uva,i-la.u Cysts romoTed during the
fourth moulb of Pregnancy, abowu by Mr. W. A.
UlBEDITH . . . . .
Sarcoma of the TTterns removed by Vaginal Hjater-
cctomy, shown by Dr. Gow
Raptured Uterus oconrring during Labour and nfter
External Violenoe, shown by Dr. JOHH PuiLLIi'S .
XXU. Note on the OpLTutiou for Keetonug the Perineal
Body in Complete Kupture of the Pemalo Perineum.
By A. E. AnsT Lawrence, M.D.
365
366
366
366
367
. 368
374
375
377
Ixii CONTENTS.
PAOB
XIV. The Pm-se'Striiig Satore ; its TTee in Complete
Ruptnre of the Ferinenm. By Febox BoxjLTOir,
H.D. .380
XV. Habitual Abortion. By A. D. Lbith Napibk, M.D. 389
Index . . . .409
Additions to the Libbabt .... 427
PLATE.
Apoplexy of tita Ovar;, OjKtic ]>itfttalioii without Rupture
{Mr. Albas Doban)
The Bight Ovary with ite Interior czpoeed by Section
PAOI
WOODOCTS.
Five Cfwes of Faerporol Eclampsia, eepocioUy illustratitig (be
Teraperature and Crine in this Disease (Or. HbbuanJ
Cuw I. Chart 1
Cmo II. GhATt 1
Case II. Chart 2
Ca«« lU. Chart I
CMC III. Chnrt2
Ca«e V. Chart I
tTrctiml Diverticuln CDr. Ahabd Roitth)
Ut«m« showiufi tho Effects of a Gangrenous Pibroid {Mr. J.
Blasd SorroN)
Pig. I . — Bection of UleroS from which a Oongrctioua
Fibroid biul bucs removed
Fig. 2. — Abdoniiaal Ostium of the Tabe
GlAnda of the Fallopian Tube (Mr. J. Blasd Sottok)
Pig. 1. — TraiiBvcrae Section through the Fallopioji
Tube of it Mnca<]Uii< Mouley, Ifaatcttt rhtttia, to
ehow the gland-cluatcra
Fig. 2. — A Compound Racemoat! Gland from the Fal-
lopian Tube of thu PanoHan Seer, Cervut etdi
Fig. 3.— Microaeopicnl Characters ot a Fallopian
Adenoma (Doran'e cose), for oompariaon with
Pig-1
DiEsection of a Fostus, tho subject of Betroflezion, Ectopia
Viscemoi, &6. (Dr. Daxin)
Fig. 1. — Sbotriag Heart, Liver, 8ac contaiQing Kid-
ney, Ac, and Intestinoe with Diat«adcd Colon
Fig. 2.^^bfiiii« ot Aortic Braiich«ji
190
191
198
202
Ixiv
WOODCHTS.
PAOK
Tig. 3. — Showing arrangQineiit of Lamins aad Bibe,
&pmB. Bifida, approsimatioii of Eachial TnbCTori-
ties, and Flexion of Spine
Tig. 4-. — Showing shape of Thdraje, Plerion of Spine,
Everaion of Ilia, and position of Coccyx
Fig. 5.— Attitude of Fffitns in ntero
Fever in Childbed. Part I. — Cfeneral Hygiene and AatiaepBis
(Dr. BOXAIL)
Chart I .... .
Chart JI . . . . .
Chart m . . . . .
Four Caaea of Pregnancy with Bright's I}ie.eaB« (Dr. HsBUAir)
Caae I. Chart 1 . . . .
Oa.se II. Charba , . . ,
Case ni. Chart 3 . . . .
Ofise of Tuba! Abortion (Mr. J. Bland Sutton)
Fi(f. 1 . — Ovarian Cyat of th« right side, with an Accqb-
8ory Ostinm to the Tube
Fig. 2.— The Left Tube op«n6d to expo&e the Apo-
pi actio Ovum ....
Fig, 3. — The Ovum in gitu . . .
Fffitan, the subject of Atresia Ani TeeicaliB (ttr. Dakis)
Fig. 1. — Showing AbdominaJ Protuberaiice, Beformi-
tieB of Legs and Feet, and Spina Bifida
Fig. ".—Cyst tallied do^vn, ehowing large Intes-
tine, &c. .....
Fig. 3.— Cyat opened, showing Pn^atatic Cavity, &c.
FigB. 4 and 4a. — Showing Mode of Origin uf Abnor-
mality .....
The Pni-se-string Suture j its Use in Compltte Rapture of the
Perineum (Dr. Pebcy Bottltok)
Fig. 1. — Complete Riipturo
Fig, 2. — Inciaions neceeanry for Restoration
Fig. 3. — Rectal Tear atit^liodi Pui-se-stringSiittiro in
place .....
Fig. 4. — Puree-string tied; Perineal Sutnreintroduucd
209
208
209
235o
23tfe
23Sc
343
369
373
383
383
.389
385
ADYHBTISBMENT.
Thb Socibtt ie not as a body Tesponsible for the focta and
opinions which are advanced in tbe following papers and com-
nmnioationB read, nor for those contained in tbe abstracts of the
disoasttona which hare occurred at the meetings daring the
20, HxHOTSB Squabs, W.
LIBRABT AND MUSEUM,
20, Hamoteb Sqdabb, W.
Honrs of Attendance: Monday to Friday, 1-30 p.m. to 6 p.m.,
Saturday, 9 a.m. to 11 a.m., and in the Eroiings on which the Society
meets, &om 7.15 p.ni. to 7.46 p.ni.
R. W. 8ATAGB,
Zi&rorMta.
TOIi. XXXII.
OBSTETRICAL SOCIETY
o*
LONDON.
SESSION isrto.
JANUARY 8rn. 1890.
A. L. Gaiabim, M.D., Presidentj in the Chair.
PraiwDl— 28 Fellowa and 2 Viaitors.
Books were presented by Dr. Auvard tad Dr. Godson.
James Oliver, M.D., P.E.S.Edin., was admitted a
Fellow of tKe Society.
Harry Marmaduko Pago, F.R.C.S. (Oxford), and
Arthur Hardwick, M.D.Dubl. (Newquay), were declarud
admitted.
The following gentlemen wore clocted Fellows of the
Society : — Robert James Carter, M.B.Lond. ; Charles
Plumley Child©, L.R.C.P.LoDd. (South&oa) ; Edward
Henry Douty, M.A., M.B., B.C.Oantab. (Cambridge) ;
Harry St. Clair Gray, M.D., C.M.GIaB. (Glasgow) ; T.
Arthur Heline, M.D.Edin. (Manchester) ; Charles Henry
JamcB, L.R.C.P.Lond.; Ernest E. Lewis, L.R.C.P.Lt)nd. j
Cbicheator Gould May, M.A., M.B.Cantab. (Doblin) ;
VOL. XXXIl. 1
2 BAFIDLT FATAL CSBSBRJU. SSUO^&EAQ^ IN A CASE OF
Godfiey Forrest Reid, M.D.Dubl. (Orange Free State) ;
Jolin Frederick William Silk, M.D.Lond. ; Charles Her-
bert Thompson, B.A.J M.D.Dubi. ; and Ckarles Porcival
White, M.E.C.S.
The followiog genlleinen were proposeil for election : —
Chrifttoplier Martin, M.B., CM. (Middlesbroagk) ; Ben-
jamin Wilfred Thomas, L.B.C.F.Load. (Welvrjo) ; and
George Porter Wornom, M.B.C.S.
RAPIDLY FATAL CEREBRAL HJEMORBHAGE
OCCUERING IN A CASE OF PREGNANCY
COMPLICATED WITH MULTIPLE FIBEOIDS.
By WiLUAM DoHCiN, M.D.
Db. WrLLrAB DdNcah showed the TiternB and kidneys of
this patient.
Mrs, S — , aged 42, was admitted into the Middlesex
Hospital &n October 25tli, 1889, complaining of swelling
of the abdomen. The catamecia began at twolvo years
of age. They Lad always been regular and lasting
three daygj and never were profuse. The patient bad one
child £.76 years ago ; no miscarriiirgeB. Tlie last period
ceaeed on Sana 10th. In Angust a email swelling waa first
noticed in the lower abdomen, which for six weeks before
admission rapidly increased in ei^e.
State on admissioTi, — A florid-complesioned, spare
woman.
Breasts enlarged, with dilated veins coarsing over
them, nipples prominent and areolae darkened ; thick
creamy Becretton could be squeezed from both.
Abdomen diatonded by central tumoar o£ elastic nafcare,
reaching an inch above the umbilicus. Surface covered
PBEOKANCT COKFUOATID WITH IICLTIPLB FIBS0IO8.
with namerous hard tnmoara varyiiig in aiso from u ^mall
orange to a marble. Intermittent uterine coutractiona,
nterine Bonffle, and fcctal heart all made oat.
Ptr vaginam. — Mucous membrane port-wino colour,
Os oteri looted downwarclB and backwards. Cervix en-
larged^ swollen, and soft. The cervical canal easily
admitted two Bngcrs. No balEottement.
Urine acid, ep, gr. 1030, trace of albumen.
The patient was kept in hospital for cliuicol purposee
for three weeks, during which time fresh tamours were
detected. Discharged from hospital !Norcrabor 15th.
Readmitted on December 25th (Christmas Day), at
12.30 p.m., in a restleBi? and comatose condition.
The following history was elicited from a friend ;—
" Since leaving the hospital patient had been in very fair
health and able to do her house-work daily ; at nu time
had ehe had any fita or conyalsiuua. On Christmas
ntoming she got up at 8.30 a.m., feeling perfectly well,
and continued eo until 10.30 a.m., when she complained
of sudden acute headache. At II a.m. she was found
totally unconscious, toeeing her armu about (especially the
right), and breathing deeply and heavily. She was
brought to the LoHpital iu a cab.
8tat« on admission.— Deep\y comatose, but throwing
arms and legs about, and moving the whole body ; move-
ments moro marked on the right side. Breathing deep,
lend, and noisy. Bespirations 40. Pulse hard, of small
Tolomef 110. No rolaration of sphincters. The eyes,
&oe, and head were turned to the left.
Catheter pasued, and ^ss of nrine loaded with albumen
drawn o0.
Dr. Duncan was at once sent for, but being absent from
town. Dr. Boxall arrived at 1 p.m.
The patient was now more deeply comafcoae ; respira-
tiomi -48, and there was total paralysis of arms, legs,
face, &o. The temperature was not taken.
The face waa of a parple hue, and so venesection was
performed, five ounces o£ dark blood being removed, iol-
4 fI/FIT)I.T FATAL CKXKHRAL HJCXO&RRAOB.
lowed by sliglit improvement, which was only oE short
duration. It was tlieu decided to empty tlie aterua. The
cervix was easily and rapidly dilated by meana of the
hydrofllfttic bag-s, and version performed, but deabh resnitod
before the delivery could be completed.
Pont-morUm examination. — Subject fairly well uouriahed.
Ccnsiiiflrable poBt-mortem stainiug. On bend of ngbt
elbow was a venesection-wound closed by recsent lymph;
the vein (median basilic] was filled by a clot.
On opening tlie abdomen a few ounces of clear BerooB
fluid escaped. The uterus (contuining many firm sub-
serous, aod interstitial fibroids averaging an Inch in dia-
meter) was found adjacent to the abdominal wcitl and
reaching to within a finger's brcftdth of the umbilicus.
Th0 organ with the vagina, and appendages was removed
and laid open from behind ; tho incision showod the
uterus to be partially contracted. The placenta and mem-
branes of a fcetus of less tliau full time occupied its cavity,
tho former beiu^ situated at the left angle and poBteriorly,
BO that a small frag-miMit of It v/aa cut off by the inoiaion ;
tho placenta scorned to*bo placed oror tho orifice of the
loft Fn.llopinu tube.
Ovnrien and tubeM were normal.
Brnin. — Considerable venoas congestion was noticed on
removing altalUcap. On removing brain a very exteneive
hsmorrbage was fouud, seemingly into the subarachnoid
spftce, which extended over the wtolo baso of the brain^
a.nd upwards, laterally, to the temporo-splicnuidal lobe?.
On incising the brain a very extensive heemorrhage was
discovered, apparently into tie snbstance of the island of
Beil on the right side ; it penetrated deeply into the
Ifttern-l and fourth ventricles.
About five oaocesof blood had escaped from tho vessels.
Heart. — Tricuspid valvfs tliick and slightly puckered ;
apparently competent. Mitral valves much thickened ; on
one was a smalt vegetation with loosely attached thread of
fibrin ; valve seemingly competent.
Left kidney. — Capsule very adhoroot to kidney and to.
kC'HCHMKTKb'h TBAWariraiON APPAKATtrS.
sutTOuncliug connective tiasue. Surface of organ puckered
and covered with multitudiuoas cjats. Cortical eubBtance
greatly wasted. Many more cysts seen within the kidney
on section. Medullary substance normal.
Alt other organs normal.
mUnchmeybr*s transfusion apparatus.
By J. Matthews Ddncan, M.D.
Dr. Mattukws Duncas exhibited Miincliioeyer'n instru-
meot for trauBfusion in cases of nearly fatal haMtiorrbiige,
aooordiDg to a plan of his and Leopold's (' Archiv {ur
Gynakologie,' vol. xxxiv, pt. 3, p. 38). By this a \iy^<i-
dermic injection of sterili«od water at blood heat, and bear-
ing in solution chloride of sodium (a drachm to a pint), was
made to the extent of one, two, or three pints. The effects
were said to be as good as when the fluid was injected
into the »eins. He had long recommended watery injec
iion directly into the veins by a common syringe ; but
this method of Miiuchmeyer's was simpler and less daoger-
oaa. The injected water had to be diffneed by manipula-
tion, and it was rapidly absorbed. Traniifufiion uf ordinary
kinds had excited and maiutaiuod great enthu^iatim in the
profession, but its uae was unsatisfactory and very danger-
ous. It had never come into practice as an established
resoarce ; and no wonder, for a lute systematic writer, while
recommending it, said it killed more than it cured.
Science bad done much to explain the bad results that
frequently followed it; and scieuce indicated, water to fill
the void cauwd by hiemorrhage to be the best Snid to
nse — the Bafest. He hoped that Miinchuieyer's method
of sabcutaneouB injection would prove a useful and bandy
rosoarce in the terrible post-partura haimorrhages. Munch-
meyer and Leopold injected into the loose cellular tissue
near the s<»putB.
OTARIAN CYST, PARTLY DBBMOID.
By C. H. Cabtir, M.D.
TWO DERMOID CYSTS FROM THE SAME
PATIENT.
By C. H. CiETBE, M.D.
LIPOMA REMOVED FROM LEFT LABITJM
MAJUS OF A WOMAN AGED FORTY.
By 0. H. Caetkb, M.D.
SHOULD PREGNANCY BE TERMINATED PRE-
MATURELY IN CASES OF PHTHISIS P
By William Doncah, M.D.,
OBSTBTBIC VSTBJtiUX TO VOX UBIlLiteHX HOBFITAJi.
(Rwrived 0«tobor SSnd, 1S890
This
was a queetioD I had to consider lately when asked
by my friend Dr. T. Cranstonn CharloB to indace abortion
for a medical man's wife the subject of advanced pbtliisis.
Tlie history of the cose is aa follows : — Mrs. B — , aged 27,
was married tour jearB ago and has had two children, the
firflt being bom ten months after marriage ; the seconti,
eixteen months after the first. The catamenia commenced
when sho was thirteen, and were always irregular, there
often being amenoprhcea for tbree or four months. Both
ber confinements were prolonged and difficult, owing to the
lai^ size of the children's heads : the first lasted thirty-
gir hours, and the second twenty«five. Chloroform was
given for many hours, bat the forceps was not used. The
placenta of the second child had to be removed piecemeal.
There was an absence of milk in the breasts after both
labours.
Family hitiory. — Oae maternal ancle died of pbthisis ;
all other relatives healthy.
Chett history. — Had double pleurisy resulting in pleuritic
adhesions seven year» ago.
Fouryeam ago (afew months before marriage) there was
congh with slight crepitation at the left apex ; the physical
signs increased during the ensuing pregnancy, and after
the birth of the child there was a decided chango for the
8
FBXaNAHCT IK CASES Of PUTDTSIS.
worse : the expectoration was more profnee ; the rdle» wero
mush louder, and -covered a large urea of the left lung,
the right lung remaining sound.
After the second conBnement she was laid up iu bed
for nearly three ruonths, the lung aig-as getting gradually
and steadily worse.
Aboub two years ago she waa seea by Dr. Quaia, who
urged the aece&sity of no further pregnancy taking place.
Pour monthly ago a cavity wfis detected beneath the
middle o£ the loft oltivicle ; the lower baU of the left
lung and the npper part of the right, near the stermim,
showed crepitation. At no time bad there been much
blood in the sputum, but occaaionally a small clot had been
expectoriited.
Id August last, as she had missed two perioda, and be-
lieving herself pregnant, she came up from Worcestersbir©
to consult Dr. Quain again ; in his absence she wae exa-
mined by Dr. Allchiu, who gave it as his opinion " that
her life would he shortened if the pregnancy were allowed
to go on."
Taking all the conditiooB present into conBideratJoD, I
agreed with the opinion above esprot^ficd, and consented to
empty the uterus; this I did as follows on September Hth.
Dr. CTanBtoim Charles and Dr. B — (the husband) wero
present. Dp. F^rederiek Hewitt gave t-hioroform.
The patient was placed in the lithotomy position, the
TuIIva and vagina well washed with a 1 in 2000 solution
of mercuric chloride ; Sinis's speculum introduced and
the cervix firmly seiaed by a rolsella. Next, the cervical
cuiinl was easily and rapidly dilated with Begar's dilators
Up to Xo. 22, when the finger was inaertod and the
foetus and raembranea removed ; then the whole uterine
macous membrane 'was carefully curetted to remove all
the decidua), the cavity irrigated with a hot mercurial
douche, and lastly a twenty-grain iodoform bougie was in-
troduced into the uterua and retained there by a glycerine
plug passed up to the oa uteri. The operation lasted
twentv-Sve minutes.
riBOKA^iCS IN CASES OF PQT016I3.
0
Tbo subsequent progress was in every res pect satisfnoiory,
tlicro was absolutely no pain whatever, ito rise of teaipera-
tnrfr or piilao ; there was a very ^ligbt sanious discLa.rge
for two days, after which there was none of any kiud.
The patitiut returned home exactly three weeks after the
operation.
Rtrmarht. — It seems to me that this subject requirea
careful cuuKidcratiuu and discsussion, for in not a siugle
text-book on obstetrics that I have consulted can I find
any montion of the induction of abortion or of premature
labour id oases of phtliisis.
It is now a wcU-Tocogniscd fact that when a phthisical
woixiaQ conooivca, tho progress of the digoEiee (inatoad of
being retarded as old authoritiGH held) is ImHteued ; tbiH is
especially the case in young women "between twenty aud
thirty years of age. I have seen several instances of it,
aud the case just recorded hears out the view.
Let us first consider early pre^^Tiancy in a phthiuical
woinan, luid then pregnancy when the child has bBCOiue
Tiable,
Now, ia the case of early pregnancy in a woman the
subject of well-marked and progressive phthisis, I think
there can be no question that the proper courae to
pursue is (alter carefully considering the case in consulta-
tion) to tmpty the uterus of its contents. And if this be
done- in the manner just described, taking every possible
prccantion against the occurrence of sepsis, there need be
_iio fear of any ill effect ensuing.
But I will go furtlicr, and maintain that the same coorso
should bs adopted in a similar case, but where tlie phthisis
is stationary ; for when we consider that the disease may
be lit into activity during any period of pregnancy, that
as a result of the expenditure of vital force consequent on
the process of labour at term, and tho degenerative changes
taking place during the puerperium, logotber with tho fact
that the woman's offspring will ino^t likely be puoy and
weak, and probably die within a few months after birth,
the advantages to the woman of having the uterus at once
10
rBSOKAHOY IS CASKS OF PBTBISIS.
»nd completely emptied far outweigb the adTantage of
goiag on to term for ttie sake of a Kriag child, oapecially
fts dcliTery nt term is almost certain to bo followed by a
more or less rapid downhill progress.
When, however, we oome to consider tho case of a
phthisical woman seen for the Q.rst time when the child i»
viable, the question ariaea in one's mind whether the better
course to adopt would be to let the pregnancy and labour
tennimLte naturally or to iodnoe labour prematurely.
PofBOnally, I ahonld feel disposed In a case of this kind
to be guided in my treatment by the Inng-condition.
If the phthiaia at this advanoed period of pregnancy
were quite stationary (thongh well marked) I should wait
nntil full term had nearly arrived, and then, in order to
save the patient all suffering and the strain on her system
congcquent on natural delivery, I shoald have her auses-
thetiaedr and (whilst carrying out every anfciseptio pre-
caution) then dilate the cervix, first using graduated
bongii>s (such as Hegar's), followed by the hydrostatic
dilators until the eerrix was sufficiently expanded to
permit of delivery by the forceps or version as the case
indicated, performing what may be termed "accouche-
ment rapide " as distinguished from " aocoucbement
forc^."
If, however, the phthiaia were markedly advancing, (t
seema to me that the interesta of the mother and child
would be best served by effecting delivery in the above-
mentioned mann&r without delay, not waiting until the
full term had been reached.
Dr. CrLLiirowoBTH apologisBd for intervening betTeen ihe
paper and tlie diecueeioD, He thought it, however, due to the
Fellowa to place them in poasesBiou of a i'ew fLddltional facta in
reference to the case before them. The patient iiiiquoaliou (who
was the wife of a medical man) bad been originally eeat to him
with & note from Dr. T. CracBtoun Charles, stating that the case
wna one of pulmonary phthiaia with pregnancy, and that it wai
seceBsary that abortion should be inducod, and asking him (Dr.
Cullingrrorth), in caee be agreed with i>i. Chulee'a opinitfa. to
PBSOVA.KCT IN CASES Of PHTHISIS.
11
firrangementi for perfortniDg the operation ftn eoon as
ble. Aft^r se«iDg tne pati&nt he sotiglit and obtained an
interview with Dr. Charlea. That ptyaician then expressed hia
belief that the miBchief in the lung would certainly increaee if the
pregnancy were allowed to go on, and that if, on the other hand,
the pregnancy were terminated, the patient, notwithBtanding
that flbcj had a cayity in the !img, could he cured, It further
tranBfiLretl that Dr. Charles had nbeolute faith in the efScacy
of a new treatment that had hoen proposed for the cure of
Salmoniry tuhercutoeis, namely, the innalation of heated air,
[e pointed out to Dr. Charles that the posRibility of cure in
such a caae was a matter of opinion, and that, if an operutioD
were performed, the reiponaibility would rest with the operator.
He aUo reminded Dr. Clmrles that it waa by no meana an eetab-
lished fact that the chances of life in a coniiumptive patient
were improved by the indaetion of abortion, which was a moat
Berioua thing to do under any circumetancee, and particularly
HO here, for he waa not aware of the operation having ever
been undertaken on mmilar groundB. He regretted that ho
could not accept Dr. Charles's views, or acquiesce in the opera-
tive trfntiiicut lie propoaed, lie liaduo alternative, therefore, hut
to decline to undertake it. Ue had heard no more of the cane
nntil that evening. He was very glad Dr. W. Duncan had
brought the lubjcct before the Society.
Dr. Hebkak asked upon what gronnde did Dr. W. Duncan
ba»e hia opinion that the existence of pregnancy hastened a fatal
tcrcoiaatiou in cases of phthisis. lie (Dr. Herman] waa inclined
to the same opinion, but his opinion was only baat'd on vogue
imprewions derired from his own experience ; he could not adduce
any evidence Id support of it, nor could he refer any one who held
a contrary opinion to any convincing collection of cases. If Dr.
Duncan could produce or quote some scientific evidence showing
the effect of pregunncy on phthiHia, be would do a groat service.
If Dr. Duncan's view were clearly proved, ho (Dr. Herman)
thought the induction of abortion wouid be proper treatnieut.
Dr. PLJ.TFAin aaid that while he must admit the interest and
novelty of Dr. William Dnncao'a suggestion, he could hardly
believe that it was one i^-hich either would be or ought to be gene-
nUy acted on. He presumed that Dr. Duucan did not intend to
noominend the induction of abortion in incipient stages of
pbtbieis, for such a course would lead to the greatest poeeihlo
abuse. Dr. Duncvi had eafegunrded against bia own action bjr
Tery properly having a preliminary coDsultation, and subttcquentlr
by submitting it openly to the criticism of the Society. It
must be obvious, however, that there might be many who would
trust to such a course without much precaution, and who would
Bfaelter themselvce under the authority of Dr. W. Duncan's
name. In MlTtDced caaca the quostioo was different. It seemed
12
PBKONANCV IN CASES DP PHTHISIS,
to htm, however, thai there vaa na eitfltoreiit groiiitd fur con-
clmjing that puttiug an end to iter labour would lualormllv vheclE
or alter the progress of the disease. Mor«(>vor, it was o t^pj
upea (juestiou whctlier, iiudcr eudi cirvumstativuB, tliu mnthor
betu^ nlreaJy the suhj^-ct of JulvmiceJ urijauic diHt^aHe. the
iuterei^ts uf ttie child should not be tuktiii iiili> cuDHidemtiun. On
the whole, therefoK, while he tiiinutt^d the force of aomv of Dr.
DuacaQ'fl argitmoutN, he believed hia case waa a. dangerous pre-
cedent, and thflt the cuurae adupted bj hica would tiot be gener-
fttly approved or fallowed-
I)r. PuiEStLEZ said that on oae poiat thoj would all probably
be agreed, viz. that no collateral coDsidcratiou ^uirli &a those which
had been alluded to by Dr. Cullingwortli sliould be allowed to
influettce pr^ctitiouers io determiniog whether it wa« right t«
induce abortion. In a paper road before the Society »»iiie yean
ago, " Ou the Iiiductinti of Abortion a* a Tliei-a|.ieutieMfaaure*'
(vol. xzii, 1880), he had laiil it down as a rule, to which there
were practically few exceptions, that abortiou was only a
legitimate Dperation when the life of the tnuther was ao imperilled
by the eonCinuanco of pregnancy that emptying the uterus
preat^Dted itaelf as the ouly alternativo to save the patient. Not
having seen the case in which Dr. Wiiliam Duncan had pro-
voked ahortiou because ihe woman wbh Buffering from plithitiia,
he could not eipresa au opinion whether or no the measure had
beeu imperatively called lor hy the urgency uf the symptomB;
but judging Irom esperience in such t-iiees. it was diiEcult to
conceive iiny eirt^umplaucea in whiuh pljlliisis, without Botne
other eompHcfttiun, would justify the proi^eeding. It was well
known that phthiaionl patients had a, fertility which wao aluioat
abnormal, aiid he believed it M-as the celebrated Culteu, of
Edinburgh, who Srat a»i^erted that phthiiiig in these patients
tieemed to be suspended or retarded by the cliances going on in
the gravid uterus. A wbole string of autborn had testified to
the itame fact ; but only recently a M. Gaulard, in France, hnd
endeavoured to controvert this asaertinn, and he averred that
there wua do pause in the pro^re?a uf tubercular dimeuKe in the
luDga duritig pregnaoey, any mure than in other dieeasee of the
luugs duriijg thnt condition. But, even if tbie questiou were
better determined, one anturally asked what was to be gained
by the induction of abortion in phtlumcal patients. One could
not pretend that it would conduce to the cure of the patient,
aud it was very doubtful if the operation would place her iu a
hetter poititiou alter it wan completed, liatlier one would fear
thai the irritation provoked by it, wheu brouglit on by auch
A method aa had been described iu this case, or indeed by any
other method, would still further impair the etruogth of the
patient, and put her iu a worse position than if allowed to f(0 to
the full time. Aa at proBent intormod, therefore, he should not
rscaMAiccv i» c&siib op fbthisis.
18
be diqiowd to mqcUod abortion in patients sulFenDg froia
phtfafiritpulmnnalis as a general tlierapeutic rue&:<uro.
Dr. CHAMipNKrB raid that, liko l>r. llertimOj he Eulij eipected
th»t, in Unnging Bucli a (juMtinn forward, Dr. W. Duncon would
have iureniigutoii the fa(;tf, nud given n summary of thi'^m. The
iufluvuve of pnL^^'iinticy uu [ilitliiniii was still ubscure; it waa iiti-
pFObkble tliiit ftny eweepiiig etittettieiit i-aiild bo tande, but siicli
AD invcati^atioQ might, tbTow tbe cu»ce mto ccrtuin groups, dc-
E ending un nui'h fuctn &b tbo kind of diecaitu and its stage. In
is KiuarkH introduotory to tliu diseustiioij, tlie PreHident had well
dividdd tbe questions raided in tlie paper into jintliologicnl and
efehicaJ. As rogu'ded the former we htul little iu the nay of cer>
taintf ; we did not know what good aburcion itid, nor wh&t harm
jiregnancy did. Ab regarded the ethical ijueation, he thought it
wa» well recognised that, where the motlier'u life was practically
forfeited, her clniina, an aj;»iiiBfc thoau of the fietiis, deatrved leisa
atl«ntioo. The claiisical irjutauce of thiH whm tlmt of a womnn
Affected with oamrflr. The life of a phthisical woman was aluo
generally forfvited. lu contruift to this we had bul-Ii a diaeaeu
aa eclampvia, which depeadi>d ou pregnancy, and which would
probably ctaey on tho coseatiou of pregnancy, leaving lbs womaji
(it might be hoped) m porfoct loaltb and with a fair prospect of
remaining !m> in a future pregnancy. In urgentcaaen of tliiasort
it wan recognised aa a proper proceeding to proevire abortion. A
SCDt«ric« ill Dr. W. Dancnn'* paper referring to the production
of an inferior child landed ue in u wry doubtful territory. If
we were to procure abortcon iu ciny case in which the charactBr
of the parents vould load us to expect a child meutully, morally,
or pbyucally undeairattle, wc should have our hands full. Then,
again, how many times ia Dr. W. Duncan prepared to procure
abortion in the aanio woman '( These phthisical women often
conceive rery rapidly. How soon did heeipeetthia lady to return
to liim with a nimilar requeet? If he was right this time, he watt
logically boond to procure abortion for her as often ae she was
piegoant. Lastly, the apoaker could not aee any reauoo for
" aeeoucbcment rapido" (i. e. accouchement force without cutting)
in auch caacs. Ke thought that, with all our antiseptic precau-
tiona, such a procedure must inrolve marked additional riak, and
that the woman would get on far better if left alone, and given
chlurofonn if neceaaary, during the second atage in the usual
war.
Ur. MArrnEwa Dttkcait said that it was not establiehed that
SregnanCy injurumsly alTectcd the- progrcmH of phthiais. A great
cal of reuearch had been made on the aubject, which was one ei-
tremely difficult of aolulion — stmost insoluble — the result being
Dneertaioty aa to whether good or evil came from pregnancy in
phthiaical women. Teriain it woh that auch women did bear fine
tivaltby children: and recent intjuirim as in the infectivenesa of
14
vB.BasA.Kcrs 1)1 cissB or phthisis.
tubercle did not lend to increaae tb« fear of danger to tbo ftctus
Trotn its coneumptive mother. He would, as a rule, deprecate
the induction of abortion or premature labour in ca«es of phthisis ;
and lie litil aot look with favour on tli« ra|)id method of deliTery
aa described, regarding it am not tlie beat, if delivery were de-
cided on.
Dr. AuAKU ]toviH thought that most obstetricians bad
obBerved thut tiiu process of lung-destructiou in phtliisis during
pregnonuy wne at s. etuDdetill, but becume very rnjiid during the
subeequent lactntion. W»« it not, therefore, more Ffltional to
prevent lactation than ta iaduce abortion? PoMibtj- in cseea of
pbtbiBiB, during the Uter moDths ol' pregnane^, when the child
was viable, and dyapnoEa becntne urgent, premature labour might
be wisely indulged, but not during the earlier montlia.
Dr. Leitu Katiee had seen a considerable number of easea
of pregnancy oecurriug in phthiaieal women. He was disin-
clined to accept the view that pregnanc;r invariably hastened
the progrees of phthisiB. Although be might mention several
caaes illustrating the eonverse, let one suffice. A patient seen
twelve years obo. auffering from well-markedlung disease — so ill,
indcud, that she bad practically but one lung — fell pregnant.
Glrave apprehensionH were entertained as to the prognosis.
Happily tlieae were contradicted by her diittiuet improvement
during pregnancy, and after poirturition she coavaleaced well.
She went abroad, was still aiive, and in fairly good health. When
abortion occurred niLturally in a phthisical woman, Tarioui
pathological factors besides the general aQffimia had to be
conaidered, Abortion in a phthisical patient, in his expe-
rience, was usually a very grave matter; it caused great strain
on the palient'B Htrengtb. In three such cases he had met
with, the lung disease progressed rapidly, and the deaths were
unqueHtionably hiistened. It might be that with a uterus un*
affected with local disease, and in an early stage of the complaint,
artificial abortion would have different results. Yet,uU things con-
sidered, he wae not prepared to accept Dr. William Dancan'a eug>
gested liine of treatment. He thought a waiting policy the wisest.
Dr. Jamison would like to ask Dr. William Duntion if ho
himself acquiesced in the reasons given for the necossity of per-
forming this operation. They were three. First, that if prema-
ture labour were induced, the tubercular diseaHe from which
the patient was auflcring could be cured by hot inhalations.
Secondly, that the children of phthisical women lived a very short
time after their birth ; and thirdly^ that pregnancy accelerated
the progress of phthisical disease. Dr. Jamison was inclined to
join itieue on each of these assumptions. Surely to speak so con-
Itdently of the cure of pbthisLs byany method of treatment, even
by hot iabalatioiie, wna not in accordanee with the everyday
ezpeiieoce of phthisis. Ua only wished pbtbiatB were as easily
FBSOKAirCT IN CASES OF PHrBieiS.
15
enrable. That the children of phtbiiiical mothers only lived a
ftbort time after birth was & atntemcDt not ia Uarmoay nitb the
CX|ienei]C« of every one in this room. He bad kaowu over and
over ieAia of tlio children of phtLleical parvnte growiag up to
mIuU Fife. In one cnee in bis exp&rieii«e tire healthy children
itero bom of a phthisical motber. Lastly, Dr. W. DuDcaa had
admitted that tncva were no alatiatJcs to prore that pre^aocy
shortened thE> duration of phthiaical disease, but he would like
to say that m^ftt writers held just the contrary view. The onJy
' French writer, of any uote, who thought pregnancy accelerftted
phthisis was M. GrisoUe. Hia own impressioa was that given
two phthiaical women, in every respect equal in extent of diacaae,
who say hod uuly tsix muntlis to livv, if one became impreguatod
she would live over nine moathe. He wonid like to point out
tbat Dr. William Duncan bad not told them whether any im.
JroTomoQt had'takoa place In the lungs of this lady, demooBtratod
y alteration in the pbyaical signs after the operation. lie
attached no importance to the statement of the patient that she
felt qattfl well, a* the feelings of phthisical people were the most
deceptive things in the whole range of clinical medicine. There-
fore, putting all together, he thought no cnac had been made out
for the extension o)' this operatiou, nor to minimiBe the fet'liog
that it wu oQo likely to be attended with grave abuae aud
danger.
Dr. ABBAnxM "Wlllxce, having apologised as a new member
■ JOT obtruding himself on the f^ociety otler the long diseuBBJon,
■aid that the pubject wbb one which intereeted him, aud lie beg^d
to offer Dr. W. Duncan his pergonal thanks for starting the
qoeatioa. He congratulated him on the result of the trualmvot
in the isHividuol caae, but cuold not accept hia general, vob-
diuioDS. Ue hod had. as a practitioner of midwil'en,- and as ■
teacher of its science, conaidemble difficulty in formulating the
principles of treatment necessary for the conduct of hia practice
aa well aa for the inatrnction of etudenta. No doubt a great deal
had been written on phthisia complifating pregnancy, eipreitsing
▼ary discordant opinions as to the effect of pregnancy and par-
tuntiOD oo tho progress of phthisis pulinoD&lis j but, bo far ae ho
knew, there were not any Indicationa given in regard to treat-
ment in tho accopted test-books of midwifery. CoQHidorin^ the
itdvftnce made during recent ycora in tho inveatigatioD of the
IjMthology and treatment of phthisiB, he thought that this par*
[ticalar luhject was deserving of Eeriousconsideratioa. He depre-
'eated the idea of the report of the discussion of this eveniiig going
librtb to the profession as an ezpreasion of tlie views of this
Society, whose influence wna ao esbeu8ivo,aad suggested thnt the
•abject lay, aa it were, on the border-land of pure medicine aud
midwifery, and ought not to be approached from tbe etandpoint
16
PKBONINCV IN CASKS OW PHTHISIS.
of tlie obsfetric specioJist merely, but re<]uired to be looked ftt in
nil Hh uept'cti.
Dr. William Dditcan {in reply) saitJ ho was very glaii tfa«
question had evoked such im active diBcuHHion, but nt tho same
time be coulil uot cjuits agree with tho opinions eipn^sKtfd by the
variouB apealterB. He must diaecDt from th? sssertiou that
" prfigtunicy sLould uot he termiuated unlese it threateaed tbe
palieut" s life; " and beaivDtioned the caseof apatieut id the Mid*
dlesex Hospital who last year bad severe puer|>erfll eclampfiia,
and recently, being 6ve raonths pregnant, was readmitted with
acuie Qepl].riti&, double uptic neuritia, and retinal bsmorrhages.
The ophthalmic niirgefin oaving said that if tbe pregnancy were
allonud to f^n on tho patient would probably bifoome blind, Dr.
Duncaa bad no he^itatioa in emptying tbe uterus. He thought that
the induction of abortion gave adietiuctadFitntage by doingaway
nritb the dangere connected with parturitioii and the puerperium.
He did not, of course, mean that alt eases of phthisis cooiplicatinf;
pregnancy cnlled for interference, but each crhd inuat be judged
or its merits, and after careful conHultation with another phyaicriiiH,
who abould share tbe reapou&ibiiity- Neither did he mean that,
hBving oace terminated pregnancy in a given cAse, the same treat-
ment should be pumuod if impregnation eubaeijueotly took place.
On the ijontrary, if tSio patient neglBL-ted the warning given her,
she (being entitled to ehoose] took the reapongibilily, and must
submit to the rieka. Dr. Duncan regretted he could give no
statistics, either proving that life is shortened in these cases, or
showing thee^octof pregnaacy on a phthiaical woman; but he
was one of thoee who did not believe much in iBtativtica : hia
statements on tbeee points were those given in all the leading
works on obstetrics.
^E CASKH OP PUERPERAL ECLAMPSIA, ESPE-
CIALLY ILLUSTRATING TUE TEMPERATURE
AND UKINE IN THIS DISEASE.
By G. Ekmesp Herman, M.B.Lontl., F.R.C.P.,
oonBTKio PuraiciAK n> iiii loxdoji uosfitix-
(Retvired Octnfacr 24lh. 1B89.)
Fttb iwies arc d«t&il«d, of wbich thp chiof fe&tures am u
fullows :
O&sB L — First prcgnivncy; premonitory ejniptouiB a few
hours only before Btn-, coiivulHiuns coiiiiiii.-uciiit{ during first
ttugo of labour At term, not ceasing witli delivery, ceasing
aEt^r morphia ; bovpii tils hi all ; tcmpomture rising Blightly
during fits, falling after c^sHation of fits; diminution in (]iiuutity
of urino tluriD^ fit* j lUureiuH after dt-Uvery und CL'sstliwu of
fits; uriue during Uta uvarly stflid wilb iilbumvti (mucli para-
globulin), blood, and oaala ; rapid dieappf^araaccof albumen and
blood aft«r dcliv«ry; diiaioisbcd elimination of urea during
fits ; increased elimination of urea following deliver}-. Gompltit«
wooTery.
Cub 2.— Second pregnancy ; prouionitory symptoniB throe
weeks before fits; intm-aterino death of ftctua ; fiu coming on
at «igbt iuontb»' pri'giiuncy ; eight fits ; fits cenAing after
morphia, and before delivei^ ; slight pyrexia, continuing four
boura after lunt Ht, tlien ubutiug ; polyuria tliruu^^Luut, t^ruipo
rarily iucruased afti^r delivery; uriue contiuuiu); liulf it;i bulk
of albumen (much paraglobulin) ; iDcreaee of albuiueu SvHoiriag
flt8 ; albumen diminiiihed after delivery, but still persiating
montlis afterwards; diminution of urea-elimtuatiuD during
VOL. XXXII. 2
IS
PDBBPEBAL ECL&MPBU.
fits; restomtiou of uri^a-eicretioD to normal, commeticitig afttt
ceseatioD of fits ; retinitia albuiuinurica,
Ca£B 8. — First pregnancy ; jiremonitory symptoms forty -eight
liours before onset of 6ta at five months' preynauoy ; about
BixteC'D fitM ; BiioulimuoUB premature delivery ; urine solid witt
nlbuQien (lai^ely parEiglokulin) ; ufissatiou of fits, fall of tempe-
rature, a.nd diminution in gjilbiiminurin following adminiatriLtion
of morpbia, and preceding delivery ; cTirainution oE uriuu and of
urea-excretiuR (botU absolute and iu proportion to the urine)
during period of fits; r«-eatahlishment of urine and urea-
excretion, coumeQciag after cessntloa of Qts and before de-
litery. Recovery.
Case 4. — Tenth pregnancy ; symptoma a week Iwfore fita, at
aeveu uiontba' pregntincy ; tbree days' trciktmciit by milk diet in
hospital brfore fite; retiaitis ^ (our fits only; morpliia givoD
after Becond lit ; death by coma live hours after last fit ; sub-
normnl temperature ; fits preceded and acf/ompaniod by slightly
inereiLBud diuresiK ; albuminuria diminished by rest and niilk
diet ; fits accom])aiued and followed by increase of albuminuria
aud hroniiLturia; steady diminution in urear-pprcoutage, pre-
ceding fit* flod continuing till death; abeolute nrea-excrc-tion
diminished throughout, but no greater diminutiou preceding or
accompanying Ets. No autopsy,
Oasb 5,— First pregnancy ; xymptums about tbirty-&ix bours
before fitb, at. eight mouths' pregnancy ; intra- uterine death of
EcetiUi twenty -four fits iu all, extending over sixty hours,
csaHtng "before delivery ; delirium for forty-eight hours after
fits; slight pyrexia, subsidiug before vessution of fits; during
period of earlit-rfita urine solid with albumen, and diminished in
quantity, but percentage of urea not diminished; imorease in
quantity of uiine and percenti^ of urea, and diminutiou of
albuminuria before ceesatton of fita. Complete recovery.
The author points out the diSerences between the cases tliem-
selres and betweoa tUem and other published cases, and draws
the iufereiicc that puerpertbl uclumpsiu is a diseast; nut haviug
a uniform clinical lustK>ry any more than a uniform morbid
anatomy.
FDERPKBAL BCLAHPSU. 19
In vol. xiix of tlie ' Transactions * of fcliis Society I con-
tribnted a paper in which, two cases o£ puerperal Bclampsia
were related. They were puWished because the course
of the renal fimction had beeu observed with exceptioual
care. I now submit five more cases in wliich aimilikr
obserratioiu hare been made.
Ca81 I . — Primigravida ; premonitory ttymptoim a few hiyitra
oniy befvre fite ; eonvulidons i-omviencing during Jirst
sUigo of labotiT at term, noi eeaeiiig tcith delivf^ry, eeaa-
ing after morphia ; nevon fts in nit; temfcraturo riinng
Uliijhtly during ftg, falling after con^ation i>f Jtls ; divii-
ntition in quantitif of urine during Jits ; diuresia after
delivery antl ce-i'-'tation of jits ; urine during fits ui'urly
golid with ulhumen («iw<-A of it paraglohuHn), blood,
and ra»t9 ; rapid diaappearanee of aliiunien and hlood
after dnlivery ; diminiahtd excretion of urea during fin ;
incrtaaed diureeis and excretion af urea during lying-in
period ; Mtnpfode recovery.
C. L— , aged 22, single, preg^nsnt with her first child,
admitted into the General Ljing-in Uospitul, -July 2tith,
1888. I have to thnnk ]^[r. U. A. Pratt, house physician,
for the notes of the case and the aualyses of the urine.
Previous hitlory. — Said to have had scarlet fever twice
and meaales twice when youug; each time recovery good.
No other ill D0B8. Begati to menstrutito at fourteen ; always
regular. Slight pain preceded flow. Last menatruatod
from October 20th to October 24th, 1887 ; duration five
days ; (|uaDtity as utiunl. During Erst two months of pri-'g*
lancy patient suffered greatly from retching and vomiting
' ID the morning immediately on rising. Slight swelling
of ankles duriug first two months of pregnancy ; none since.
During remainder of pregnancy felt very well. Has had
a white vagtnul diucharge for tbo past three weeks. Move-
ments of child Brut felt in February, 1888.
Hittory immediately precediity admission. — Falieut'e
aooouul was that en July 20tb, 1888, she went to bed.
so
PtJtRrKIUt. KCLJUirsU..
feeling bb osualj at 1 B.m. July 21 st, woke feeling slight
pain in abdomen, unci water running away. Came to
hospital, but was stnt back as not in labour. At nooa*
21at, patient felt very ill, " ill all over/' but had no pain.
At I p.m. alight " show." Admitted 1.30 p.m.
Mother'* account. — Patient has seemed battor than aennl
dnrirg pregnancy till the morning of 2l8t, when sbo com-
plained of iieadache ; she also put her baud to the front of
her chest, eajiug ehe bad a pain there through to her
shoulderB, a " sinking pain." Patient was eick three or
four times during the morning, "the vomit being streaked
with blood." The last time there was " only bile," Her
bowels wero open twice before leaving home.
She states that she was a, " funny bloish colour'" all
the morning.
Has ne?er had fits ; there ia no family history of epi-
lepsy. Never complained of her sight.
On admisRiion, July 'il^t, 1888, 1.30 p.m., patient pale^
but mot aniemic. Well developed. Nothing strange
noticed in patient.
VaQinal e-raminaiion. — Cervical canal obliterated, 08 sixa
o( florin, edges thin, dilatable. Blight show. Vertex ia
catity of pelvis in second position. Membranes rnptured.
Doucho and oncma ordered, the latter acting freely.
Patient passed uriue several times, which was described
by nurse as being normal in appearance.
Pains regular and fairly strong, iiiercasod after enema.
At 4.15 p.m., while patient was on the night-stool for the
purpose of pasaing water, she was suddenly seized with
twitobing of face and hands, and became very stiff. No
oiy. A nnrsc who was standing at patient's sido imme-
diately placed her on iho floor and prevented her from
biting her tongae. The twitcliiuga lasted throe minutea ;
patient then began to foam at the laoubh, becoming ahghtly
livid, and remained in a drowHy condition about half an
hour ; she then had a short period of complete conscious*
ness, anewering questions readily.
During the fit the conjunctival were iasensitiro ; the
POBUFCBAI ECtAMPgl
pupils were equal ami of moderate aiap, reacting refldilj"
to light. 4.30 p.m., Chloral Hydrate and I'ot. Brom. aa
gr. XXI, given per rectum. 5 p.m., second fit, lasted tlirco
minutes, affocting botb sides of face and body. Remainod
drowsy about ten minutes. After fit pulse lOO, rcct&l
temperature 998'^. 6.5 p.m., fit. Juration three minutes.
PuUe 98, temp. 39'8°. 7 p.m., fit, duration four minutes.
Pulse 106, temp. 100°. 7.45 p.m., fit, auratiou four
minutes. Pulse 120, temp. 100-6°.
The head having advanced to the pelvic outlet, at
8.30 p.m. chloruferm waa given and forceps applied.
Child living. 9.3 p.m., fit, stronger than former odcs,
daration four minutes. PuUe Iltj, temp. 100*8°. 10.12
p.m., fit, stronger, duration three minutes. Pulso 132,
temp. hOO'S". 10.40 p.m.. Been by Dr. Herman, who
ordered hypodermic injection of morphia, gr. J. 11 p.m.,
sleeping.
July 22nd. — Patient etill sleeping, haa taken food ia
{orm of milk and beef-tea freely when roused. No moro
iita.
23rd. — About 2.30 p-m . yesterday afternoon patient woke
up and asked if she might see her baby, auU osprcseed
herself as feeling very well. 11 a.m., Pulr. Jalapoo Co.,
gr. zxx, given. 8 p.m-, rep. pulv. 12 midnight, bowels
not acted, enema ordered. Has taken milk aud beef-tea
freely.
24>th. — Very good night. Enema was repeated in the
early morning, but only acted slightly. 10 a.m., Pulv.
Jalapte Co. ^j. Patient ^ays she feels very well, no head<
ache.
Oiihihiilrrtuscupic examination. — Nothing abnormnl de-
tected. Takes food well,
25th. — Steeps well. Aftor two cuoiuas bowels acted
freely. Patient is now taking Mag. >Sulph. 5] in a tnijc-
taro three times a day. There are bruises on arms and
logs, caused during the fits.
2l3th. — Patient coutiuues well. No headache. This
morning her arms aud upper part of chc«t are covered with
PDBHPgBAI. ECLAMPSIA.
23
a vesiculo-papulfip rash, which itches greatly, BowoU
veiy obstinate, only one slight motion nfter several doses
of Mist. Sal. Aper., Eneraa, and 01. Crotouia ny.
80th. — Patient very well ; was np yesterday for first
'time. Bowels still obatiuate, open once jcHterday after
01. Ricini ,=fj, which was repeated in two hours.
August 5th. — Discharged.
Tetttpcraturc, — On admission tho temperature was 07*4",
Aft«r first fit it reached lOO'-t' in the rectum. AJt«r
second and third fits it reached BS-S" in the rectum. It
was taken just hefore fourth fit and found to bo 100"4°,
' after the fit 1 00°. After fifth fit it reached 100-6°. After
delivery it was lOO'S", and remained the same after nixth
and seventh fits. From 10 p.m. on the 21at it wuk taken
hourly till midnight on the 28rd. It continued at lOO'S"
(or three hours after last fit, and then gradually fell ;
after thia it nevor rose above 100" during patient's stay
in hospital.
Urijif, — All the urine waa saved and examined during-
patient's stay in the hospital, with the exception o£ the
80th, when Eome was logt, tlie nurse failing to pass the
catheter hefore Btool. The urea was estimated with
Squihb's apparatus, aud ou several occasions was inde-
pendently examined by Dr. Herman with Jerrard's appa-
ratus, and the results found practically to agree with those
given by Squibb's process. For the first thirty hours the
'-nrine woa hourly examined quantitatively for urea: after
this it waa all mixed together aud examined onoe in the
twenty-four hours.
At 1 1 p.m., July 21&t, the bladder was found to contain
32 c.c. of urine, at 12 midnight 42 cc. When the catheter
was pn8.?od at 2 a.m., July 22nd, uo urine could be ob-
tained, at 3 a.m. only 10 c.c. found in bladder, and none
at 4 a.m. After this the quantity varied from 4-2 c.c. to
134 c.c, with the exception of 1 1 p.m. on 22ud, when only
10 c.c. could be obtained.
The quatitUy of urine passed per diem varied from
18 to 55 OS., the daily averago being 30 oz. The first
24
PCERFBKAL KCLAMPSU.
dny after delivery 85 oz. were passed, on the fifth day
49 OK., but OD tlie sixth day only 18 os. were paatied m
twenty-four hours. On the ninth day only 8 oz. o( urine
were Kaved, a considerable quantity being lost at stool on
this day.
Hfr-cific gravity — The ep. gr. of the urine paased after
the last fit was 1030, this heing the highest recorded. Ono
fiamplo o£ urino passed the second dfty after delivery had
a sp, gr. of 1005 ; this was not accompanied by any marked
increase in quantity seerotod. After this tlio sp. gr.
varied from 1008 to 1020, the average being 1013.
Colour. — All the urine secreted while patient was having
fits, and for two hours after the last fit, was port-wine
coloured. The sample of ui-iue drawn off three Iioura after
last fit wa» a bright red colour. Ten hours after last tit
the urine wae amber colour.
Blood. — The quantity of blood in urine diminished
rapidly after last tit, so that none could be detected with
the cyo ten honre after cessation of fits, but the ozonic
ether and gnaiaeura test gave a faint bine ring eleven
hours after last fit ; none could he detected hy this method
twelve hours after.
Casts. — A few granular blood CHsts were found in the
Si-st aaraplea of urine, but they were uf ver nuinerous, and
none were found after the first day.
AUmmen. — The ariiie secreted while patient was having
ftta, and for next two honrs, turned solid or nearly solid
on boiling. Tlic qnantity of albumen then rapidly dimin-
ished, BO that in three hours after the last fit it only
contained one-third albumen, a faint cloud only being
fonnd Bpventeen hours aftoi- last fit.
Four samples of urine were osaniiued after having been
shaken up with sulpliate of magnesia and filtered. The
ilri«t sample examined in this way was drawn off one hour
after 1a.st fit, and after the separation of the paraglobnlin
gave only half as much [n-ccipitate ati that containing both
serum-ulbumen and paraglobulin.
The next sample was drawn off eleren houra after laat
rttERPESAL souvrsu..
25
fit, and f^aTfi a precipitate of one-sixteenth albumen, After
eepftration o£ paraglobulin only a famt cloud could bo
obtAinect. Tho remRining tn-o specimens each g&vo a faint
cloud on boiling both before and after treating thom with
sulphate of magnesici, but not enough to deposit at the
bottom of the test-tube. No tiaco of albumen could be
detected wheu patient was discharged from the hospital.
Una.' — The uriijc secreted during period of fits con-
tained 2-16, 2'09, and 2-36 per cent, of urea. In the first
twenty-four hoHrs after delivery the hourly percentage of
urea excreted varied greatly, the lowest beiug 1*7G per
cent, and the highest 2-84 percent. In the second twcnty-
foor hours the hourly secretion reached 3'38 per cent. In
the first twenty-four hours after the fits had ceased, the
quantity of urea soeroted was 457 grains ; on the second
day 310 graitifi. On the sixth day after delivery only
1 76 graiiiM wen* secreted, which wr» much below the
quantity secreted on any other day during patient's stay
in hospital. The kind of food taken and the getting up of
the patient had little or ao effect on the quantity of urea
secreted.
October 2'ith, 18S9. — Child died from con vnlsioue, aged
two months. T^ticnt now thinks herself quite well.
Married September 15tli, 1889. Last menBtrnation July
7th. Catameuia regular since discharge, no pain. Now
thinks herself four months pregnant. About as sick this
pregnancy aa in the former pregnancy. Urine free from
albumen.
This case fBTOurs tho opinion that the pyrexia which
ftocsompanieB some cases of eclampsia h duo to tho fits.
While this patient was having fits the temp[>rature steadily
althongh slightly rose; and when the fits had ceased itas
Bteadtly fell. Tlie lempemturedttring the lying-in period
does not call for special remark.
The case also shows great diminution in the quantity
of urine, and in tho amoanl of urea excreted during the
26
PUERPERAL HCL11IF8I1.
fits, The qunntity of urine and amoaat of urea 7aried
nearly pari paa^u. After tlie fits the excretion gradunlly
began to riao, but its re-establishment did not scora to
begiu until six liours after the tits had ceased. The last
fit was at 10,12 p.m. Between .3 and 4 a.m. no urino wag
passed into the bladder. Between 4 and 5 a,m. urine
again (lowed into tlie bkdder, and from this lime the only
change which took place was in the direction of increase.
The re-establiahinent of the excretion of nrine is there*
fore not a condittoa which necessatily precedes the cessa-
tion of the GtB. The fits cease Brst, and then, after an
iiitervftlj the excretion of urea Bgain risttg to the normal.
Ill the five (Jays following the re-establiahmeut of the
urinary Becrottou thore was an excretion rnth^r exceeding
that which is usual in a healthj person \ymg in bed on
low diet. This diuresis and augmented urea- excretion
reached its height on the third and fourth daya after
delivery; on third day -iO oz. of urine, containing 520 grains
of area, were passed.
Daring the stress of the disease the hourly excretion
of urea varied much, without tho cause of such -variation
being discovered.
Daring the lying-in period' there were great variation*
in the amount of urine ou different davSj but no cause for
these variationa was perceived.
Case 2. — Beeundigravida ; jiremrniitirry sympfnvia three
weet« he/ore JUtt ; JUx raming on at eight mimtli^
preffnanctj ; intra •■iiterCne death of /(.tine ; tight Jitu ;
Jits teaming after worphiu, hefore delivery; slight
pyrexia, cuvfimiing four hour/' iifler last ft, then
falling ; polyuria Ikroughout, temporarily increaffed
after delivery ; urine containing half its hvlk of aibV'
men, largely paraglobiiitn ; increase of olhuminuria
fnliuwivy fils ; albuminuria ff-imininkud after deliverif,
biif. Ktill permMitiff seven mtytitha nftenoardg j dtmtnii-
tion in excretion of vrea during jtt$ ; reatoration of
PPBUPERAL ICL4MP3U.
27
normal UTeu'eUjiiiitatiun i-u-miiiettc-iiig after cessation
of Jits ; retinitis aViuminurira. (Tlie notes of the onso
were taken by Dr. H. G. Lys, Kesidt-nt AccouclieuTj
and Mr. J. H. Wilkinsok, Cliuicol Clerk.)
C. K— •, aged 2<% admitted into the Londou Hospital
January ICtU, 1880.
Patient had never had fits before, nor h&d &uy of her
relatives suffered from fits.
Slie had had one child twelve months ago, and during
the last six wwuka of progiiiiuuy with it suffered from
"dropsy." WLva aduiitted she believed herself to be
eight months pregnant. She had tiufferod frem morniiig
Tomiting throughout the whole pregnancy, worse for the
last two months. Between two and three months ago her
feet began to swel), and for the last three weeks her eye-
lids and face bad been puffy. For three weeks she had
complaiued very much of headache. Three weeks ago she
had a fright. On December 26th the patient (who had
obtained a card entitling her to the attendance of a mater>
nity pnpil in her confinement) sent to the hospital under
tlio idea that she was in labour. The student who went
to 800 her found no indication of labour, but advised Iter
to come in on account of the dropsy. For the last two
■weeka she had slept badly. About a week ago she com-
plained of not being ablo to mo, and ever since then ber
keight had been getting worse. Ou the morning of admits
sion she did not seem able to ehq a light. She alao
complained of " water in her eyes and at the back of
her head." Throughout the night before admission she
' wan delirious — her husband said " raving," — getting out
of bed and walking about; she did not recognise her
husband that night. She had nover complained of epi-
gaatric pain.
At G a.m. on the morning of admission the patient fell
down in a fit in her room. A quarter of an hour after
ahe bad another lit j and a quarter of an hoar after that
a third fit. Hhc had two mure fits before admission,
S8
PUBEtI>ERA.L m!.\MP3lk,
the last one being in the cab nt the gates of the hos-
pital.
She wns Admitted at 10 a.m., January Itith. On
admission sho was vory restless, continually turning' from
side to side and on to her KancU and knees. A. quarter
of an hour after admisaiou she had a (it. After this she
Iny more quietly, breatliing heavily. Ten minntes after-
wards »he had a eerenth St. During this the adminis-
tration of chloroform was begun, with the result of appa-
rently checking the fit. After this the putieut breathed
heavily for about fifteen minutes, and then sfemed to
sleep quietly, only crying out at inten-als. At 1 1 a.m. an
enema of sulphate of magnesia was giveUj but produced
no effect. At n.4-'>a.ni. a simple euema was given, which
rBturned as it came. At noon the patient bad so far
recorered coiiBciousiieaa as to ask where she was and
where her mother waa. After this she became more
restless and violent. At 2 p.m. an eueraa was givea con*
taining Chloral 588. and Pot. Bromid. ^sb in some milk ;
and -]^ gr. o£ pilocarpin was injected siibcntaneously.
Abont 3 p.m. the patient slept for half an hour. At
4 p.m. the euema was repeated, and she became qnieter.
Before this she was so violent that she had to be held
down.
Abont 4.30 p.m, ehe was seen by Dr. Homian, and the
folluwing note was made : — Potient very restlesB ; breath-
ing with short calchiug inspirations and long hissing ex-
pirations. Pupils were widely dilated before the admiuis-
tration o£ chloroform. Uterus hard, containing but little
liqnor amnii ; fundus reaching two inches above the
umbilicus. Much oedema of legs, flight oE abdominal
■wall. On Tiigiunl exaiuiuatioa cei-vis softened, undilated.
Pulse regular, l^t) per minute, full aud hard. Cardiac
dulness reaehes to the left, just outside nipple Hue. No
murmur. No abnormal sounds over Sunga. Liver dnl-
nees reaches from lower border of Hixth rib to costal
margins. Splenic dulness not increased.
At 4.40 p.m. the patient had another fit. Half a grain
PDSRPBBAL tCLXMniA.
29
ofmorpbia was tlien given hjpodermicallj. 8 p.tn.— Since
tbe tnorpliia injection patient has been sleepiDg cjuietly,
with noisy breatliing; pupils small. Passage of CHtheber
provokes violent movements of resistance. Os uteri size of
a tlorii), membranes unruptured. 8.45 p.m., patient very
violent wIienroua«d; Morph, gr. ^ and Atropiu gp. jjV g'™"
hypodermicully. 10.30 p.m. — Patient slept after last ia-
jcction tiU t*n o'clock, then became so restless tliot she had
to be hold down toprerent her from flinging herself out of
bed. Chloroform was given. The ob was funnd almost
fully dilated, the membranes nnrnptnred ; the Lri'ech pro-
senting, dor«o<>poKterior. At 1 1 p.m. the membraueH were
ruptured, and delivery easily effected. The placenta waa
expressed without difficulty, and there was no unusual
beemorrhaige. Fcctua decomposing. After delivery the
chloroform -lUiBBstliesi a passed into sound sleep. Slie
fllepb continuounty throughout the night, only rousing
Trhen the catheter was parsed.
17th, 9 a.m. — Patient eat up, &aid she was dry, and
asked where she was. Between 0 and 11 a.m. took half
a pint of milk. Throughout the rest of the day was quite
qniet and rational, not even relenting tho catheter. She
continued to take milk well, and excepting when roused
for thia purpose and the catheter, tilept throughout the
day. She recognised her friend?. There was much
cedema of face, neck, and legs, although the latter had
diotiQisbed in size since admission.
18tb. — Slept well through tho night. Occasional coiigli
throughoat night and to-day. (Edema less. Pulse 120
to 139, Ophthalmoscopic examination made, and appear-
ances of neoro-retinitis found. Slept throughout tho day
except when ronned. Bowels open twice, loose. No
vomiting, no complaint of hcadnche. Occa-sional rhouchi
in longs, no other physical signs. Still taking milk only.
I9th.— Slept well hist night, and to-day is not drowsy.
Aakti for more to eat. In the afteruoon severe headache
came on, left-sided, lanting till evening ; patient says tho
headache she has of late suffered from ba» always been
PDIBFERAL ECLAKPSU.
of this kind. Polae leas froqn«nt. Tongnc dry. Bowels
open five times, motions ^een and very offeosivo. The
©yea were examined by Mr. Waren Tiiy. He reports that
the changes are singular on accoaut of the largo size of
the white patches, their semi-transparent rather than
chalky appearance, and the email nil tn her of Roialler
glistening patches and absence of sl-reaka ; also for the
sm&ll number of haemorrhages, of which there are only a
very few small ones iu butli eyes ; the white patches aro
all on the outer sides of t!ie diaca, but not chioBy in the
yellow spot regions (where there are only a very few emalt
gliBtening patches), but rather distributed down and ont,
and up and out, from either disc.
20th. — Bowels open six times sinte yesterday ; cha-
racter of mottoas same. Complained of occaeional nbdo-
xainal pain throughout the night, less daring the day.
No headftche or di-owsinesn now. Cough and lung signs
about the aaiue. Skin dry. Pul»a about the same.
Takes food well. Slight tenclernesa over right lower ab«
domen.
Zlst. — Bowels open fivo times in the twenty-four hours j
stools no longer green, but brown and liquid. Some
griping pain in abdomea. No headache, slightly drowayj
in morning.
22nd. — No more abdomiual pain. Bowels only open
once ; motions brown and loose. Pulse 112, No Tiead-
Bche or drowsiness. Her progress after this was ontirclj
satisfactory.
80th, — Allowed to get up.
February Hlh. — Vision -3^; reads 20 Jaeger. Di»«.
charged.
Ikmjffrrnture. — The teraperatare at 8 p.m. on the day
of admission {the patient then having had seven fits, the
last of them about four and a half hours previously} was 99".
At a p.m. (the pationt having in the interval had anothorj
fit) it was 100 . From this time tho temperature wa»'
taken every hoar or two honrs (according to circum-
stances] until the end of tho third day. Its maximnm
FOKKPEEUL BCt-AMFSlA.
93
daring the stress of the discBse, 100*6°, was roftclied at
0 p.m. on tlic day of admission. Then it sankj reach-
ing uoriunl at 1 a.m. During the whole of the next
day it dill not exceed 99'2*. On the third day there
vraa a rise of temperature, liegionlng at 0 a.m. and
reaching a maximum of lOl''!^ at 2 p.m. Then it again
fell, and at midnight was DS'S". There wns no conspicu-
ous change in paiient'a condition to Recount for this riso
of temperature. After thia the temperature remained
uormal.
Urine. — As far as possible all the urine excreted was ool-
lectod. The catheter wns pns-ieil on adraiseion, and every
two honrs subsequently. Some urine tvas passGd into the
bed in the iulervalH ; this of couree could not by measured,
nor could that which was passed by the patient along
with the raotionti. The quantity withdrawn by the catheter,
measured and shown on the accompanying chart, is there-
fore less than the total quantity excreted. The number of
motions is shown on the chart, so that an idea may ba
formed of the amount of urine which escaped meaeuro-
ment by fwcompanying them.
Quantity. — During the first twenty-four hours 74e ok.
were withdrawn ; in the seconil twenty-four hours 52 oa. ;
in the third twenty-four boui-s it reached 118 oz. During
the sevenly-twi) hoiira which followed there was diarrhooa,
and thie probably accounts in part for the diminution in
quantity on these days which the chart ahowg. Daring
the three periods of twenty-four hours to which this
applies, 08, 22, and 22 ox. wcru the qnantitiuti withdrawn.
Then the chart shows a gradual increase in quantity each
day, till on the eleventh period of twenty-four hours,
86 oz. were collected. Duriug the remaining four days
in which the urine was measured the daily quantity was
from 56 to GO oz.
The quantity of urine was thus throughout, if allowance
be mude for nnaroidable incompleteness of collection,
above the average of health. This ioorcase in the quantity
passed was present during the height of the disease, while
VOL. xxxn. 3
FtTEBPBBAL ECUUIPSU.
the patient was having the fita. Delivery was followed
hy temporarily increased diuresis.
Specific gravitij. — As might have been expected from
the increased amount of urine, its specific gravity was low.
It was especially low while the patient was having fit-s.
That of the urine drawn off at tho time o£ admission and
Bubsequentty up to 4 p.m. [tlie last fit heing between +
and 5) was only 1007. At C p.m. the specific gravitj' of
the nrine tad risen to 1010, and at 9 p.m. to 1012. Thus
increase in the density of the nrine coincided with cessa.-
tion of the fits. The dimtnut-ion of the ijuantity of urine
on the fourth, fifth, and sixth days, which the tabic shows,
although DO doubt partly accounted for by mach of the
urine Laving* been lost with the etools, yet woald eoem
partly due to greater concentration of the urine j for at
the satne time there was a rise in the specific gravity,
which reached its luaxiunim^ lOH, on the fifth day. This
KpBcifie gravity was again reached on the seventh day, tho
tiimntity of urine passed on that day, exclusive of that lost
with oui> action of the bowels, being only 36 uz. After
that the specific gravity stood at 1012 or lower throughout
the patient's stay in hospital. The specific gravity was
thus below the average of health much in proportion as
the quButity of urine was above that average.
Alhmnen. — The amount of albumen present in the urino
WM measured by precipitating it with boat and nitrio acid,
letting tho nrine stand, and then roughly measuring the
amount of precipitate by the eye. The nrine drawn off
on admissiou gave a precipitate of quite half ite bulk of
albumen. The next specimen, drawn off at 2 p.m., did not
contain quite so much — about three eighths of its bulk.
That drawn off at 4 p.m. contained still lessji — about one
third. Hetwecn 4 and h the patient had a fit, and the nrine
drawn off at 0 p.m. contained two thirds albumen, and that
at 7.20 p.m. three quarters [dbumi-n. Thisincreanu in the
amount of albumou following a fit is noteworthy. There
waa not quito so much in the urino drawn off at 9 p.m.,
about one half; and in that at 10.40 p.m. (shortly before
TVBBPEIUL BCLAHPSU.
35
delivery) two thirels. At 1 a.m. — that is, after delivery-
it had sunk to one third. It tbeo went on dimimshing
till, at 2 p.m. the ucxt day, tbci-e was only oue sixth.
Aft«r this the amount again iocreesed a little, and tLrougU-
out the rest of the patient's stay in hospital the nrino coix-
taioed from n quarter to a lliird of its bulk of albumen.
Specimen!? of orine were from time to timo tested to
• •■certain the proportion iv wliicli the iilhumen was uom-
^poeed of parnglobiilin and serum tilhiimen respHCtlvely.
The specimens passed on the day of admission showed, on
treatment with sulphate of mag-uesia, a considerable Ioosr,
flaky procipitAte tif paraglobiilin, amounting, when the
nrine hftd been allowed to stand, to about one third of its
balk. After separating the paraglobuHn by filtration and
treaticj^ the Sltered fluid by boiling and nitri« acid, there
was still an afjundant preoipitate. Specimens drawn off
at 7 a.m. and at 6 p.m. on the day following admission
(and delivery) «lio»Ted, on treatment with sulphate of
lagnesia, only a small flaky precipitate, too small to bo
F<atimatcd by bulk, A similar small precipitate was ob-
'ieined From nrino passed on Jammry 18bh nud 19th. On
January 2Ist (the 5ixth day] the tiuantity of paraglobulja
had Blink to n mere trace, and this trace was present
throughout the rust of the patient's stay in hospital.
Depotii. — The first two specimens of uriji© contained
■ Tory little, if any, doposit. In alt the sabsequent speci-
nena there was a flaky white deposit, oxcopt ou the second
and (bird daya, when the depuBit was rud^ probably due to
I a Blight admixture of blood, possibly produoud by the
'frequent use of the catheter. MIcro.scopically the deposit
thronghoQt consisted of abundant gi'anular casts and uric
aoid crystals.
Urtn. — Ou admission — that is, while the fits were recur-
ring— although the quantity of urine was above tha average,
the amount of urea elimiuiitcd in it was much below tlio
average ; not only below the average of health, but below
the amount that one would have expected to find iu urine
of that specific gm\nty. During the first twenty-four
$6
PDIRPSBAL ZOUJit^i
bonra only 168 grains of urea were foond to have been
excreted j in the second twenty- four hours 183 grains.
Then the chart shows that tie urea-exeretion ran np to
ite uormal quantity, 484 grains being elimiuated in the
third twenty-four hours. After this the curvB showing
the urine quantity tind that of the urea quantity run close
to one ftuother, while on admission the urea curve is far
below the urine curve. The hourli/ variaiian of the nrcji.
percentage is ah own on the same chart as the hourly tempe-
rature. On admission it waa only "3 per cent., and it re-
maiued at tliig until after the last iib had ocouned. Thou
it immediately bega.n to rise, and rose with tolcroblo
pagularity, till twenty-eight hours after delivery, i. e.
thirty-sis hours after the last fit. Delivery does not seem
to go wllh any marked change in the urea curve.
Swyar. — Tlie urine was many times examined for eugar,
but none was found.
Bendion. — Its reaction was acid thronghout.
February 19th, 1889. — Patient came back to report
herself. Urine pale, acid, up, gr. 1011 ; urea I'l per
cent. ; proportion of eno fifth albumen ^ uo paraglobuUu ;
no sugar.
August 3rd, 1889. — Patient looking well, not ansemic.
Thinks herself well, except that sight ia imperfect. Urine
containing one third albumen.
In this cascj although rise of temperature followed the
fits, it did not follow so itmnediately as to favour the
view that it was directly au effect of the fits. The case is
remarkable and exceptional in that the quantity of urine
waa increased instead of diminished.
The cessation of the fits was followed by immediate in-
creaee in tht) percentage of urea, in the nrino ; hut restora-
tion of the urea excretion to the normal amount was not
complete till twenty-four hours or more after the cesHation
of the tits.
87
Cask 3. — Pritnigmvida ; ■premonitory nymptoms forty -eight
hours before omef of Jits at Jive months' pregnancy;
about ^ieen fits i sponianfonf pr*;pintiiTe lahour ; cea-
imtif/n of ft' ; fall of te7n2>emf.urp. nn.d diminution of
alhumiauria foUowiiifj ndministratimi nf morphia ani
ynetding efsHvery ; diminution of urine and of urea-
excTtiion (both abmlute und in, proportion to the urtfie)'
during fits ; partial re~cslabliahmcnt of urine and «rf;ra-
eacreiion after cessation of fits and before, deliicrij ;
fuine solid with albumen, lartjeltj parntjlnbulin. (Ke-
ported hy Dr. U. G-. LySj Resident AccoucKeur.)
M. G — , ftgod 20, admittod into tho London HoBpital
Maroh 3i-d, 1889.
Patient had always previously had good health. No
fits. Sh« was married eleven raonths ago, and miscarried
two months aftrr marriage. She now thialcs herself about
BIX montba pregnimt.
Aboot 7.30 a.m. on March Ist aho began to complain
of beftdacho and paia in tho lower abdomen. On March
2nd her eyelida woro nuticod to be swollen, her headache
vraa worse, and sho had much pain in the lower abdomen
Rod loios. About 10.30 p.m. on chat evening she began
kto feel siclc. On Maruh 3rd at 3 a.m. she began to vomit,
'fend vomited on and off till 9 a.m. At 9 a.m. she had a
fit. During the day other fits recurred, the patient being
said to have had about a do/.en. She was reported to
hare passed a good deal of water into the bed since the
fits began.
She was admitted at S.45 p.m. At 4, 4-.30, and 5 p.m.
she bad epileptiform seizures. Each fit was preceded by
theavy breathing for about five minulea, aud began by
twitching of the thumbs, which was succeeded by general
clonic spasms. Strong contraction of the ntorns was
noticed during tho fits.
At 5.15 p.iii. half a grain of morphia wan given hypo-
' demiically.
At 6.30 p.m. the following note was made : — Pntient
FTEIIPKSAl CCLAVT8IA.
lying fjiJiot, l)«t constantly groaning. Pulse 88, full and
bard. Patient fiorid a» to complexion and niQCons mem-
branes. No mnrked ccdema of face ; slight oedema of
legs. Cardiac duluess bonnded ou tho left by nipple bne.
Nn murmnr; no ubuormol sounds over lungs. Hepatic
dulnexs not incruaticd. Spleen not felt. Fundus uteri a
finger's breadth below the umbilicus. Pains occurring
every quarter of an hour or oftencp. Oa uteri jii8t admits
finger; cervical caual not obliterated.
7.55 p.m., another lit, chiefly right Bided, beginning in
right thumb and extending up arm to trunlt ; lasting three
miuutes. 10 p.m., patient very restless, but has had no
more fits. Condition of utenis mucli the snme. Morphia
gr. ^, and iitropiii gr. a'^^, given snbcutaueously.
March 4tb, 7 a.m. — Very restless. Slept on und off
thronghout night ; struggling wlion the catbotor was
paBBed, end also waking at frequent intorvals without this
oaase. 8.45 a.m., cervical canal obliterated ; oa externum
the bIko of a shilling. 9 a.ia., morphift gr. jt, atropin
gr. ^, given subcutaneously. 10 a. in., fcotue, of about
five months' gestation, expelled. Chloroform given during
removal of placenta ajid douche. 10 p.m., patient has
slept all day except when touched. In latter part uf day
has taken plenty of milk. To-night is more rational and
lees violent; knew her mother.
15th. — ConvftloBcenoe lias been uninterrupted since last
note. No more fits. Now gets up, and icAa quite well.
Temperature. — Ou admission the toinpcrature was 101*.
At 5 p.m., the patient having had throe fits, it had risen
to 102'4* ; then it began to fall, and continued to do bo,
although about 8 p.m. the patient had a fit, till 10 p.m.,
when temperature was lOO". At the time of the In.'it fit,
8 p.m., the tempornturp was lOl", and an hour afterwards
101'4'^. Between midnight and 2 a.m. the temperature
rose to 102'3", without further fits or any marked coincident
change in the patient's condition. After 2 a.tn. it r&pidly
fell) reaching normal by 8 a.m. After this, throughout
the patient's etay in hospital, it never exceeded 100°.
PUEBPEBAI ICIAUPStA.
Vrine. Qumility. — During the first forty-piglit Boors tlhe
catlieterwas passed overy two houi-s, and tlie urine measured.
But little if any was passed into the bed. The amoiintB
recorded represent the actual excretion as accurately as
is possible in the cnse of n female patient. T!ie
chart bIiows a great diraioutloQ in the quantity of urine
during the period of recurrence of the fits, a slight in-
crease in quantity during the period from the ceseation
of tho fits until delivery, and a oonaidemble and rapid
rise in tho quantity of urine after delivery. From 4. to
fi p.ui., that iSj from adtnisHioii till the ceaaation of the
fits, the average amount of urine was about half an ounce
per hour. From 9 p.m. till 10 a.m., the time «f delivery,
it averaged not quite three quarters of an ounce per hour.
During the twenty-three hours following- delivery it
averaged about 2 oz. per hour, During tlio first forty-
eight hours the measurement and esnmination of the
urine were carried out under the immediate superviaiou
of the Itesident Accoucheur, Pr. H. G. Lys ; and I
believe that the figures given are as accurate as they
conid be made. After thia time, other duties prevented
hJ8 giving such close attention to this cnse; and al-
though instructions were givon that all the urine should
be Kaved, the Bmalt amount collected makes it seem
donbtful whether or not this was faithfully done. But
the smallness of the amount whs noticed at the time,
and every care taken to impress upon the patient and
nurses the importance of saving the whole of the urine.
Borne was of course lost when the bowels acted, and tho
number of motions is shoivn on the chare. I bolicvc that
the facta are recorded as accurately as they could be in a
female patient. The quantity of uriuo which was collected,
and which is shown in the chart, is considerably below tho
average of health.
8f«eifit gravity. — Unfortunately I have no record of
the specific gravity before deliver}'. Its variations after*
wards do not permit any iuferenc* to be drawu from them.
^Wumen.—Ou admission, the urine contained so mach
4S
PUEBPEB&L ECLAUPaU.
ftlbainen tbat on lioiliog it became eolid. That drawn off
at 9 p.m. (the last Bt haviQitr occurred an hour l)c£oro)
only contained half its bulk of albumen. At 1 n.m. tLo
qnaotity of albumen hod sunk to one fonrtb. The urins
continued to contain about thia (juautity till the spocimoa
withdrawn five hours after deHvery, which only contained
one sixth. Nineteen hours after delivery there was only
one twelfth of albumen in the iiriue, and the next day
only a trace. A small quantity, about one fifteenth, waa
still present when the patient left the hoepital. The alba-
ntiuous precipitate, which on admission rendered the urine
solid when boiled, was largely composed of paraglobuHu.
Thia, when aeparately pracipitated, amounted to about
half tho bulk of the nriuo. When next examined, five
hours after ths la^t fit, the albuminous precipitate having
then sunk to a quarter, there waa only a traes of para-
globulin present. The nrine was afterwards frequently
examined for paraglobulin, but either uoiie, or only a
trace, waa present.
Frea.— This was estimated by Russell and West's hypo-
bronaate process. The results (stated on the chart) show
during the period of the fits a diminution both in the tola]
urea excreted, and also in the percentage of urea contained
in the urine. Trom admission till Q p.m., that is during
the period of the fits, the percentage of nrea was '84, and
the arerBge anionut of urea excreted per hour was l'62i
grains. This rate, if continued for twenty-four houra,woQlcl *
give about 30 grains as the daily excretion. From the
cessation of the fits till delivery the avernge percentage
was 1'24 grains, and the average hourly excretion 4'42
grains, a rate which would give about 106 grains as tbe
daily excretion.
It will be seen from the chart that there were great
differences in the percentages of urea from hour to hour.
I BUI unable to offer any explanation of these variations.
They 60 struck Dr. Lys, that he frequently twice estimated
the nrea in the same specimen, that he might OToid acci-
dental error. Dr. Kingston Fox has published some obser*
IJtkl KCLittrsU.
43
ratioBB vhich go to eKow th&t in tiealtb the amount of
orea excreted per hoar is a tolerably conetaut quantity,
both during night and day, while sleeping and vraking,
whether the urine bo ropions or scmity. If this ho ao,
tLa BnotaatiouK in this cnso would seem a feature- duo to
the morbid oondition of tlio kidneys.
DeposU.—'Tho urine withdrnwu on admUsion gave on
cooling a deposit of lithates. This was present in roost of
the Kpccimons examined until after delivery, when uric
acid ciystals were found as well. After delivery, casts
were aonitht for with care, but not found. The urine
before delivery was so &caDty, and eo niuob of it wm uaed
up in estimatiiig the urea, that little w&s loft for micros-
copical parpoacs.
Sugar.— On March 9th, lOth^ and llth the urine con-
tained a trace of sugar. This was probably galactosuria.
There was no sugar present at any other time.
This case dues nut HUpport the view that the rise of
temperature is an effoct of the fits, for after three fits had
oooarred in rapid succession the tempcTatnro began to fuJl,
and oontinned to do so in spite of the occurrence of
another fit. TIio quantity of urine during the fitx was
diminished, but only a partial rc-estnbliabment. of the
excretion accompanied the cessation of fits; more com-
plete reHtoration followed delivery. In this respect, that
only a partial re-itoratinn of renal function apparently
enilioea to stop the tendency to fits, the case is like the
two preceding ones.
I ha¥e tried to trace the subsequent bistory of tbis
patient, but have failed to do so.
Cask 4.— -Teaifc pregnancy ; »yvij>loms a week hefore fiit at
$evBn monthe' pregnancy ; three dayn' treatmani by milk
diet in hofpitnl hoforc fitfi ,- relimtif ; four /tie only ;
morphia given after second Jit ; death hy coma Jive hours
after lasljii ; tuhnormal temperature ; fit preecdid and
aceompanitd hy diureitis ; albwminuria diminithed hy
44 FUBRFBRAL ECLANPSU.
rest and milk diet ; Jtl" accompanied and foUou'ed by
infrfane of albuminuria tind hematuria; steady dimi-
nution in vrea'purceninijfi. 2>'>'''-ceding jUs and rontinmug
till ilmth ; ahuolute ftiaittiltj nf urea-excretion drmi-
■ni^hi'd, hut no grenter diminution jtrecedtng ur accom-
panying Jits. (Reported by Dr. H. G. Lys, Resident
Accoucheur, and Mr. W. C. Atlwabd, Clinical Clerk.)
L, M — > agsd 37, admitted iuto the London Hoepitat
March 2ist, 1889.
Family ht^tonj. — Father died from " feroncliitis," oged
fifty-six; mother from "bronchitis and dropsy," aged
forty-four ; one brother was found dead in bed, agod thirty-
two, canse of death said to be "asthma and brouohitis ;"
oneaister died, aged twcmty-soveu, of " consumption." Two
of patient's children died from ^'couviilsions,'* one from
"bronchitis," and one from "consumption."
Persmial hinttiry. — Until this iiJness patient said that she
had had good health. She had had smallpox when aged
three months, aiitl scarlet fuvt-r when aged nine. She
began to menstruate at fourteta, aod was always regular,
except during pregnaucios. She waa married ot twenty-
one, and had had eight childron and one miscarriage. All
the children were bom at term, living and healthy. The
labours were easy. In 1881, about two or three months
after the birth of the sixth child, she had n " tnniour *' in
the left side. She came to the hospital, was Admitted^
And while in hospital the tumour " dispersed.'''
Patient coneidcrs herself seven mouths preg'naut. She
complains of sllg-ht cough and shortness of breath ; but
chiefly of dimness of sight. This came on four days ago>
and has been getting worse since. It seemed at first ns,
if there were a film over her eyes, and now everythiuf
looks hazy.
The patient on admission was somewhat nniemic. The
enlarged utenis reached between three and four inches
above tbe umbilicus. The foetal heart was audible. There |
was slight cedema of legs and feet, but none above the
POBBPRRAL ECLAMPSIA.
45
; tione ot face j no ascites. No abnormal signs over
houri or luugs.
Ophthalmoscopic Citaminatton. — Right eye : inner part o£
disc swoUoa and margin lost, outer part wliite and not
apparently swuUyn ; duwuwarda and outwards from tha
disc an irreg'iilar white patch; signs u£ other sucli patches
commencing, and small hfemon'hages id outer part of field.
Left eye : disc similar in appeiirauce to right, cominenc-
ing white patches in onter part of field, and much larger
patches of hBamonliage than in right eye.
Temperature was uormal, aud uriue contained one
quarter of its bulk in albumen.
The pationt was put upon milk diet, kept in bed, given
Ferri Amm. Oit. gi'. v, three times a day, and instructions
were gizen that all tha urine passed Bhoald be saved for
meaanroniDnt and examination.
March 2ith. — Patient complained last night of pain in
chest, and did not sleep dnrlng the night. At 5 a.ni. she
had a fit; at 7 a.m. another fit. Between the two lita
and after the second fit she completely regained conscious*
ness. Half a grain of morphia was given after the second
fit. This was followed by sleep, which gradually deepened
into coma. The pativut hud a third ht at D a.m., and a
fourth at 10 a.m. — a very long one, attended with extreme
lividity. The breathing after tliis gradually became
heavier and slower, the pulse smaller and weaker, and the
patient died at 8 p.m.
No antopsy was permitted.
'i'einpi^raturc. — The heat of the body never exceeded
normal. It was normal on admission, and on the morning
and evening of the 23rd (the day after the litx). It was
taken at 7 a.m. and aguin at 0 a.m. on the 24th, but the
thermometer did not rise above 56'^.
Urine; quantity. — It has been mentioned that instruc-
tions wore given that all the uriue pattaed by the patient
should be saved. The boweb acted twice on the 23rd (the
day before the fits), so that on this day some urine was
loftt. From the time of admission till S a-m. on the 22nd
46
rUBRrCltAL BCLAHPSIA.
40osc. of uvine were passed. From 8 n.m. on the 22nd
to 8 a.m. oil tlie 23rdj only 24 oz. From 8 o.m. to 8 p.m.
on tho 2'StS, 21 oz. From 8 p.m. on the 23rd to 8 a.m.
on the 24th — that is, during the twolvtt hours, in the latter
three o( which the fits came on, 38 oz. The fits were
therefore not preceded by any diminution in the (juantity
of urino, but rathor hy nn augniBntatJon. On the 2'lth
the cnthoter was agnin poBsed at 9 nud 1 1 n.m. and at
2 p.m., and in r11 16\ oz. were withdrawn. Thi.s rate of
oxcrelion, continued for twentj-Four hours, wonld give 06
OS. of urine. The fits in this case were therefore preceded
and ac'compunied rather hy diuresis than hy diminution in
the amount oi urine.
Specijie ■gravity. — This ranged from 1010 to 1015. It
was LOlO on the day of admission ; on March 2drd 1012.
That of the 38 cz. passed in the twelve hours endinif
March 24th 8 a.m. was 1010. The specific gravity of tho .
urino drawn off at ft a.m. was 1015; that of the nrine a-ti
2 p.m. 1014. Tho disease does not thoroforc appear to
have been attendod n'ith any diminution in the excretion
of urinary solids.
Alhumni. — When patient was admitted the urine con-
tained one quarter of its bulk of albumen. Its quantity was
estimated roughly by the eye after precipitation and
skanding. Tlio day afLi-r admission tho quantity had snnk
to one tenth, and on tho 23rd, the day before the fits, to
one twelfth. Tho nrine of the twelve hours ending S a.m.>
March ^-tth (fits in the last three hours of those twelre),
contained one third of its bnik of nlbnmen ; and that drawn
off nt 9 a.m. and 1 1 a.m. was almost solid with albumen.
That withdrawn tit 2 p.m. contained Gve sixths of ite bulk
of albumen. The nrine paased on the 23rd (before the
6ts) was examined for paraglobulin, and this was found
present, bnt unfortunately no not© has been preserved as
to its quantity, and the urino was not a^in tested for it.
Id this case it will be soeii that diminution in the amount
of albumen followed treatment by rest and milk diet, and
that the lits were accompanied and followed by great in-
PXTEBFSBAL ECLAHrSU.
47
CTC«80 m the Bmoont of olbnmeo. Thero is no evidonee
whothcr or not ttio fits wore immedintBly preceded by an
increase in thu auount of albumen ; but uo sach increase
loDff preceded tHem.
Urea. — The percentage of urea was estimated by the
hypobroiDBte process o( Itui-sell and West. The percen-
tage was thronghoat. below the average, and below wbat
would have been expected from tbe specific gravity of the
urico. On admission, tbe percentage was '7. On tlie day
foilowiog it baa risen to "f . Next day daring the twelve
boors before that in wbich the lUa occurrod, it fell to '8.
Then it went on steadily diminishing until death. The
urine passed duritjg the twelve hours, in tho latter threu
itt which the fits occurred, contained 'G per cent, uf ucRn,
That drawn off at 9 a.m. contained tho same. The speoi-
men obtained at 11 n-m. only showed -5 per cent. ; and
in the urine withdrawn at 2 p.m. (an hour before death)
Ihoro Yvas only "4 per cent. But although the percentage
of urea thus sicaclily iliminishcd, tht* total excretion of
nrea, although much below the average of bealth, did not^
during the period of the 6t9, fall below the average of tho
preceding days. In the Iwcnty-fonr hours following ad-
TDi38ion 154 grains were excreted ; in the second twcnly-
foar hoars 103 grains ; in the third twenty-four hours
(in the last throe hours of which tho fits occurred) 21S
grains ; and in the six hours ending an hour before death
30 grains, a i-ate of which, if kept up, would give an
amount for the twenty-four hours of 156 graina.
Deposit. — In the first few days the urine was clear,
giving no deposit. The urine passed between S a.m. and
8 p.m. on March 2Jird was reddish in colour, and gave a
deposit of blood. Between B p.m. on March 23rd and
8 a.m. on March 24th, it was port-wino coloured, with a
deposit of blood and casts. The subsequent specimens
wore black, liko porter, and gavo a deposit of blood discs,
granular and epitbcltnl cast?. In the last specimen, ob-
tained an hour before death, there woro aUo orates.
The reaction wan acid throughout.
48
PUBBPSIUI. ECLAKPSU,
No augar was present.
This case ia remarkable, in ttiat the temperature was
uever aboro uorcnal, aud sank to Bubnormiil before death.
Tlioee wLo regard puerperal convulsions ns beiug BoraQ-
thing different to ordinary arteiiiic couvulsiouM would per-
haps regard ttiis case as one oC urtemia, not of true
eclampsia. But there was no history pointing to chronic
kidney diaeasp, nor did the symptoms resemble those of
ordinary acute nephritis. The fits were neither preceded
uor accompanied by diminution in the quantity of nrine,
uor by any grcftter deficiency in the osoretion of urea than
had been present at u time when the patient did not pre-
sent grave aymptoma. The only explnnation that I can
suggest IK that a persistent deficiency, even though not
great, in the excreting power of the kidneySj may hare
led to cumulative retention of urea in ihebleod and tiasues
which at length reached the point of exeit,ing convulsioua.
I refrain from offering any argument on the question »b to
whetht'^r it he urea, the uou-excretion of which is really
the important factor of so-called Hr[eraic seiauree. These
cases do not eeera to mc to afford a basis for the discusaion
of that question. Another important point also arises oat
of this cnacj viz. whether the morphia contributed to the
fatal termination. The patient's condition was worse
after the morphia than before it. The evidence (of which
the other cases related in this paper form part) that in
many caees of puerperal eclampsia the use of morphia is
followed by a favourable termination is now so abundant
that I do not infer, from the clinical history of this case,
that the morphia was injurious. It may be that there is
a claaa of cases, to which this one belouga, in which mor-
phia is harmful. Further researcli is needed to show thla,
audj i£ there be such a claes^ to define its characters.
Cabs 5. — Primigravula ; symptoms nlout thirty-six hourit
heforc JitSf at eight noJitht' pre^nmicy ; intra-vterine
death oj'fa'lus ; twenty-four jits in ail, extending «ver
ITKBrElSAL. ECLAUralA.
49
mrly hours, and cramng he/ore ifeHrerjj ; iJr.Hrium for
foHy-eirjhl hmirs after fits ; flhjht pyreMit, eubindiiig
before ccpxfttion of Jits ; duri)i<j tints of anrltor Jits urine
/rt/lui tcilh iilhiimen ami dhiinisfied in quccntity, but
pertentage of urea not diminished ; increttsc in qvnntily
vf ttrine and percentage of urea, and diminuUon of
alhuminnria h^fore vensaliun of fits, (Roportod Vy Dr.
F. Howard Tajlob, Resident Accouclieur, and Mr. W.
DtilOAN, Clinical Cleric.)
S. S — , DKcd 3-^, admitt;«d iuto bhe London Hospitalj
May 2iat, 1889.
Family hi-nionj. — Fnthor died suddenly of licnrt discftsc,
aged 49 ; mother, of asthma, aged 44. No history of
iusauity iu &Dy relative.
PrwiouH history. — Pntlont first tneusli'iiati'd at BixtL'en,
nnd wan always regular, wIlhuuL piiiu, uuLiI lier marniige.
Shu had always enjoyed good lieuUh, never having liad a
day's illne.<>» until tho present. fi3iu was married eight
tnoutiis ago, autl believed herself to he eight mouths preg-
nnnt. During tlio last mouth she had freqncntly com-
plained of fftintnesa towards evening, feeUag as if miablo
to do her work, but Lad never octuolly fainted, or loft
any of her work tindoDO. Excepting for tbiS] she was
(|uite well milit May 10th. On that morning bor husband
aaid she complained uf a feeling of great weight aud pnin
Duder botK breast^ extending to Iho lower abdomen. TLia
lasted all day, and she had no appetite. Bet^ond tbig she
Laxl uu cotupluint. Iu the early part of the uigbt of May
19/20 she slopt fairly well. Before daylight sho began
to suffer from nauscii. She vomited sereral times during
the morning, aad thruughout (ho day at intervals of from
one to two hours ; the vomited matter waH yellow and of a
so-called " bilious " nature. In the afternoon of May SOth
she begun to complnin of frontiil headache, and theso sym-
ptoms continned till the cvonjiig. At 7 p.m., while in
bedf she ooaiplaiuod of fcoling giddy, as if the room vera
going round, aud theu xhu bad a 6c, epileptiCurm in the
VOL. zxxii. 4
50
FUEKPEIUL KCLAUPStA.
characters described, wliich was followed by a aliort poriod
of stupor. After tliiti abt recovered couticiuusneas only
£or a mmute or two, and then had a second fit, which was
followed by more prolonged stupor. An hour after she
had a third fit. Then alio waa conscions for two or three
hours, bat before midnight she had a fourth lit. After
midnight fits recurred with iucreasiog frequency. From
1 a.m. to 2 p.m. on the 2Ist she ha.d fourteen fits. In tho
intervals she never properly recovered conscionsness, and
sho frequently vomited. She sometimes passed water
during tho fits. About 2.30 p.m. patient was broujjht to
the hospital and admitted.
At 3.20 p.io. the following note was made by Dr.
Herman : — Patient is reported to have had a fit at 2.30
p.m., was admitted at 2.40 p.m. No fit since. Patiout
is rcBtless. Has not spoken since admission. Popils act
to light, ConjuiictiTic sensitive, although Mousitivoness
soema diminished. Features swollen, ©cehymosoB round
eyes, black omsts about lips ; hands very livid. No cedema
anywhere. Uterua reaches nearly half^vay between nrabi-
lious and enuifonn cartilage j no npprpcinble dilatation of
cervix. Cartliac duluess extends to a iingov's bruadth
outside nipple line. No murmur at apex. Much rattling
from mucus in air-piissages.
3.50 p,iii. patient had a fit, followed by coraa, with ster-
toroQs breathing. The stertur lasted about ten miuutes.
After this tho patient lay for the most part asleep, iutorvEilii
of restlessness occasionally intervening. At 9.35 p.m. sho
was given a draught containing Chloml Uyd, gr. xxr, and
Pot. Bromid. 3SB. After midnight sho WflB able to take
milk.
May 22nd. — 7.30 Ei.in. sho had a fit like the former
ones, epileptiform. After this she remained without any
sign of consciousness till 2.30 p.m. Then she spoho to
the nurse, and after this remained conscious till 10.10
p.m., when she had another fit, followed by a short period
of stupor.
4
b2
HriBPIftAL tX-I^HI-BlA.
TIiu&u wvrv left aided, sud wore not followed by sncli deep
comti as was present- iifter tbo earlier fits. Ab 9.20 a.m.
the patient begnn to trcmbluall ovor, but f&id she did not
feel cold. At 9.50 tlie trembliug ceased. The tempe-
rature at 9.-15 was 100"; at 10.45, lOl-e*. It tlion fell,
reaching normal by 4.-1'), At 11. ^S a.m. patient coui-
plaiacd of pain in the lower abdomi^u, luii) siiid she fell
Eometliiiig coming away from her. Thts nurse toukod, and
found tliat tho child had been expelled into the bed, Tho
foetus was uiacarated, and apparently about seven month-n'
development. The resident accoucheur was then cnlled,
aud expressed the placenta with some difficully nbont half
Bu hour after the birth uf thecliilil. There was but little
LieiQoiThage. Half a grain of crgotiu was injected 8ab-
cutanoously after tho delivery of tho placenta. At 2.50
p.m. piitiont began to x'oniit, and this coutiiiued inces-
Hantiy UU 8.15. The vomited matter wna yellow, acid,
bilious-loolcing. Bliu uuniplaiued oecasinnally of pnin in
the head and abdomen. The nursH also reported that
she " talked strangely ;" fancied that she could see people
and things.
24th, — Patient slept Fairly well during' the early part
of last uight, except that she was a little restless at
times. She wok»at 8.15 a.m., and soon after waking- com-
plained of headache. During the day she was rcsllcfw,
and vomited once er twice. She took nourialnncnt fairly
well. About 6.30 p.m. she suddenly became TioloDt,
clntohing at the nnrsOj and s-aying she was being poiBoned,
killed, &c. She was given Morphia gr. \, and Atropiu
25th.^Aftor tlio administration of the morphia and
utropin the patient slept till -1 u.uu, being wakened about
every two hours for the administration of brandy and
milk. About 4- a.m. kKo became rather excited and
talked at random, but showed uo violence. Then she
slept and perspired very profuaely. About 5.30 a.m. she
was wakened, and spoke quietly and rationally, complain-
ing ot giddiness. U) a.m. pntiout ^turted up in bodj
poicRrBnAr, bclaupsia.
68
snying tliero was n mouse running ov«r it ; asked for her
clothea, and talked contiiiimlly abuut mice, saving th&y
wore rnnning about tlio room. At II a.m. a duse of
atropJD, -^i was g-ivco ; but as this failod to cjuiet her, at
11.20 a.m. Morpbia gr. ^ was g'iveii. At 11.50 a.m. the
patjont went to s\cop, and slept, excepting when roused
for Food oi* modiciiio, till 4 p.ui.
26lh. — During this day slio was cjnietor, sleeping a '
gixjd deal, and sensible when awake. She vomited four
or fiTO times, but took a fair ammmt of noiirishiuent.
27th. — Patient .slept last night ii-oiti 0.30 p.m. to 6 a.m.
Talked a good deal in her sleep. No inoi-c vomiting.
In qaieter and rational.
iSth. — Patient had a good night, only waking to take
food. Is this morning quiet and sensible, atid answera
questions rAtionaliy.
SIst. — Pationt sloops and takes food well. Locbial dis-
eharge nalural.
June 7th. — DUoharged,
Temperatitrp. — The l-omperHtnre was taken every hour
until twenty-four honrs after the last fit. Then it ivaa
tiiken every foiir hours for a, week. From that liniL' till
patient's discharge it was taken night and uiorniug. Oa
admission (pationt liavin>j; had eighteen Hts during tho
I previous nineteen boiii-s) the temperature was lOif. It
iraa ^O'S" an hoar afterwards, when tho patient had tha
first 6t after admisBiou. During the next fourteen hours —
tlint is, up to the time of tlio next fit — it varied between
PO'g" and ]00'6°, huTing fallen from the latter point to
100 2° at the time of the fit. Then it gradually fell, and
at the liaio oF the next fit (viz. 10.10 ou the oveiiiug itf
the day Fullowiug admiiutioD) was 07*8° During the noxb
nine buurH it remained Hubnorraal, and during this itme
the patient hatl twn moro fits. Then came the attack of
trembling already mentioned ia the notes, in the two
huurt foilowing which tho temperature roae to lOPO".
In tUo next two hours it fell lo 101^ and three hours after
that hud become normal. I cunuot offer any osplunation
KCLAXPSU.
of this brief ris© of teraperatnre, auless the naental per-
turbation caused by the onset of labour pains bo accepted
ail sufficient. After the tenipcrafciiro liad subsided vomit-
ing began. During tlie next day the tcmpepatnrc was
nonuttl until 8 in the cveaiug, when it rose, reaching-
101*4* at midnight, nnd 102'4° nt 4 a.m. Then it again
fell, being normnl at midda)*- This elovfition of tempera-
ture wfts Accompanied hy montnl excitement, and as the
teraperntm'G coutiiiued to riso during sleep produced by
morphia and atropin, I am luclined to think the mental
excitement depended on the febrile state, ratlier thai) that
the temperature depended on the mcui&l exoilemcnt.*
After this no noteworthj' clcration at temperature oc-
curred.
Urine. — Instructions were given that the urine should
be drawn off hourly. Notwithstanding that thi» nus done,
the imtic was so frcquentiy passed inbod thnt it was inipos-
siblo to collect «U or nearly nil that wn« passed, I think
that the hourly uae of the catheter waa too frequent, and
I am inclined to attribute to it the irritability of bloddei*
which defeated the object of the catheterisation. I give
the results obtained, imperfect as they are. AUhuugh
they do not give, as it were, a complete picture, yet they
Furnish glimpses which are accurate us far ua they go.
Qaantittj, — The chart shows the amounts of urine
drawn oS when the cutheter was not nnticipiited by in-
fluences causing the bladder to empty itself. The cutheler
was not passed till an hour had elapsed from the last
emptying of the bladder, so that each amonnt withdrawn
shows the hourly excretion of urine at thnt time.
Tho dots on the chart show the amouuta actually
drawn off. The crosses indicate that the nrine was
passed in bed, or with tho stoola, or in a fit.
During the first seven hours the attempt at collecting'
all tho urine was ttucce<ssful. The chart shows a rate of
• IIoiuiu {'ZeiUcli, £ur Oub. iind Ojn..* Band xv) Iim brouBlit forward
cvidorii-'u a* to tLie coniicvlioji bolwi-uu pyrciJii iu tlic ptierpuml state and
iiH-utal djatiirbitiice.
TTIERFFUAt. KCUUPSrjL.
5£
Qrino oxcrction vnrvinff from zero to li oz. per liour, an
average of about 3:Ifi minims per hour, about ono third
tho nvepflge of Iienllb. We omy safely conclude that in
this case, at tlie Leigbt of tho diaeast', the quantity of urine
excreteil was much diminisTicil. Then, unfortunately,
cotnes a long period in which most of the iirinp was lost ;
but the resnits of occa&ioual ciithctevism .show that the
amount of uriiie was still scanty, ^ oz., 2 dr., and on two
occasions none at all, heiug the (]iiai]tities of urine Found
in tho blikddcr au hour after urine had been passtid. Ahont
twenty-four hours after deHfery the chart shows increas-
ing amounts of urine to have been ponrcd iuto tho bladder,
i^ OE., 2 oj!., 3 oz., 4 07.., and 4^ oz. being withdrawn by
tho catheter. This inoi'c abundant excretiun of urine took
pinco about the kbiuu time as the later fits, which were
followed by briefer coma than the earlier ones. Tho
largest quantity of urine found to have been excreted in
an hour, vix. 4i oz., immediately preceded the last fit.
After this the returna are too incomplete to be worth
record. But the fragmentary observatiouB which I have
recorded show that during the stress of the disease the
qaantity of urine was much diminished, niid re-establish-
meat, and it eeoms iudood incroaae, in the amount of nrino
excreted, preoeded the cesHatiou of tht fits.
Specific griimtfj. — The quantities of urine withdrawn at
each ealheterisation were too Rraall for the specific gravity
to be easily ascertained. I therefore have only records
of the specific gravity of different specimens of each day
mixed together. On tlie day of adriilssiou the spE>ciHc
gravity wais 1Q-I4. I havu unfortunuteEy no record of the
specific gravity of the next day ; hut on the third day
(the lust St having boon at 7 a.m. on that day) the specific
gravity had sunk to 10:20. No important variation ia ob-
serrablo after. The speciSc gravities were as follows T
Hay 24th (fourth day), 1020; May 2.ith, 1024; May
2Gtb, 1025; May 27th, 1025 ; May 30th, 1024.
Albumen. — On admission the urine was nearly golid
when the alburaen was precipitated, &nd each specimen
64
POKHPRBAL KCUHPSU.
withdrawn contained a little blood. On the following day
the amoaut of albumen hnd sunk to about hiilf ; a little
blood was still pres&ut. On the tliird day {day of cet«nlion
of fits and delivery) the qnantity ui albumen was about
the BADie, hut there was no longer hlood in the nriiie,
which from this time oiiwai-ds gave a deposit of urates.
On the Eoarthday theqaaatityof albumctthadsunk to about
one fourth or one Bfth ; ondu similar uniDuut was pi-est-nt
during the next two days. Ou May 27th the ulbuniiuuria
had stiuk to oue teuth. At the time of discLarge there
was a scarcely perceptible trace.
Urea. — The percentagu of urea was ascertained by the
Eussell-West hypobrouiate process. I am indebted to
Mr. Duigan for his trouble in doing this. The collectlnn
of the urine being so imperfect, I refrain from attempting
any estimate of the total rjuantity of urea eliminatod.
The percentages of the different specimens are shown
on the chart. It will be seen that the percentage of
urea was not at &U Jiminisbed. Ou the day of admicsion
it corresponded to what would have been expected from the
specific gra\'ity of the urine. On the two following days
it was alightly increaKed, and was in escesHof what would
have been inferred from the specific gravity. Then it
sank, and later on, when the albumen had diminii^hod lo
a trace, tho percentage of urea again correBpouded to the
specific gravity of the urlue.
Depofrit. — On May 30th gome granular casts were de-
posited. At no other time wore casts found in the urine ;
but as the quantities examiued were very small, I do not
from this infer that casts were not present.
October 2l8t, 1889. — Patient has not menstruated since
the middle of July. Thinks herself pregnnni. Uterus
presents all the Higus of pregnancy at the period stated
by patient. Patient complains of headaclie, coming on
BTerj' other day, and lasting all day, but thinks herself
otherwise well. Is not antemic. No cudenia.
Urino 1010, acid, clear, do albumen.
In this caao the njcurronce of fits was protracted over
POBRrBKAL RCLAMrSU. bi
a longor period tliau usual. Tlie case also kIiows iTmt
ri«o of temperature is at least aoi an iuvariablo ecquol oE
the fits. It aUo snggcats tlwit tho coma following the fit
is not im effect of the convcilsiou, but that cooviilaion and
coma are alike eiloctg of the moi-biil condition (-auBitigtlii-
fopoier : for iu this case fits coutinued to rocur, ulfhuu^'li
the tentperatnre vva.s falling and the aiiiount nf iirine in-
creasing ; biit tha later (its differed from the earlier otips
in not beings follonrod by [irolungcd comu.
GRNBRAr, Hkharks.
These live cases appear to me ta exhibit facta bonring
opon tnnjiy poitita of interest in the clinical history of
oclautpsin. But T shall only dwell iipen one point, wlbich
appeorg to me to be the main odo which tliey demonstrate.
They go to show that puerperal eclampsia is not a disease
Imving H unifurm tyjiical clinical history, any more than
it haa a anifonii morbid anatomy. Kchanta,* who I1118
givcu tlio fulleftt accoiint3 of the morbid unulomy that I
am ncquainted with, found the fotlowiujf different renal
changes pru&cut: — ttcuteticphritts, chronic Ilright's disease,
acute nephritis upon chrouio lardaceous disease, hydro-
nepbrosis, ditutatiou of ureters and renal calices, and in
otber csHes no renal change appreciable by tbo unnidod
BODseit. Now, wben the post-morlem chaiigfesaro so various
one would espect differences in the clinical history iilsn.
Tiio resoarclies of Boiirneville, Galabin, Quincke, iiiid
otheni, show that many cases uf eclampsia avi^ accompnnied
by ulevaiiuR of Icmporature, which in fntal ciiscs siuadily
rises until death. Clalabint expresses the opinion, winch
I think has much in its faTour, that the c-tcFntion o£
temperature is duo to the fits. H Ihin be correct, the
elovatioD of temperature eliould bo somewhat iu prupor-
• ■ Arcli. fur Ojn.,' BntiJ iTiii, S. »77.
t • Mufiual of UiJwir^ry,' p. 299.
{ ■ fituitr* cliniiiuei vt tlitnuan'.ftlrii^tiea tar Im maladiM du Ajttcai« net-
i,*S*fiw., F«ri».lt»7S.
PriRPEBAL ECLAMPSIA.
tion to the omnljer of tlie fits, anfl tlie fits ahoiilcl be fol-
lowed by rise of teiuperuttii-e. Boiirnevillet has drawn
a diatiaution betweeu puerperal eclampsia aud ordinary
urfBnii», by contratiiing' the rising temperature of eclampsia
with the falling one of iirfemia. Hippolyte,* regarding
pyrexia as an essential feature of the disecise, quoto»^ cases
in which treatment by bEeeding, clilorofonn, and chloral
was followed by lowering of temperature, the trt-atment
niid the falHtig teQipenituro being by him regarded as
cause and effect, and the latter therefore a. proof of the
efficieuoy and value of such treatment.
From these five ca-ses I can exprcBB no opinion as to
whitt may be true ia the majority ; but these show that
tin- general i?;fltions cjuoted do not hold good of all cases.
In the only one of these cases that was fatal the tempera-
ture was never above normal, and fell to subnormal before
the termination. In Case 5 the fits were not followed by
a rise in temperature, but by abatement of pyrexia, the
body teat sinking to normal although fits oontinned, I
may also point out that in Cases 1 and !) tlii? teniporature
rose slightly after ehloml and chloroform had been used.
But without a more exact knowledge than we at present
have of the conditions upou which the temperature inthiit
disease depends, we cannot safely conclude that alterations
in the temperature are the effect of treatment.
It is stated iu most text-books that in this diseaae there
14 a great diiuinutlon in the quantity of urine. I do not
doubt that this slateDieut ia true of most cases. But in
Case 3 of thi^ eerie.s there was copious diure&is during the
6ta, still further inereased after delivery; and in Case 4,
the (atal one, an increase in the quantity of urine passed
preeedeil the fits and nccomptmieil them.
It is well known that ntbumiuuria rapidly diminishes
in these cases after delivery. In Caries 2 anil 5 the albu-
minuria began to diminish after iha ceBsatiou of the fits,
and before delivery. It has been maintained that the albu-
minuria is due to the fits ; and in its bearing on this theory
* *!>« r&lnuipiio iiu<!i'|i^nilt(,' Purie, 1S7K p. 329.
PUEKPERAI. ECrAMPfll*. 69
Chaa 2 is interesting, id wbicli the fits were follonred hj
an increase in the ainoant of albumen iu tite urine.
In all the cases t!io excretion of urea was diinin-
islied during: tlio Sts. Tliere was in mot-t & diminution
both in tho percentngo of uroa and in the quantity of
urine. In Case 2, in which tho qnantity of urine was
above tho average, the perceutag-e of nrea was mnoh
diminished, so thnl the riite of urea-elimination wasscaTOPly
half that of health. In the case admitted for Bright's
disease, in which convulsions supervened, and dealh fol-
lowed, the excretion of urea wa.s throughout bt-low that
of health. In all the patients who recovered, increase ia tho
elimination of urea followed cessation of the fitsaud delivery.
I put aside controversy as to the part which urea in
tho blood or tissues plays in exciting convulsioun. It is
sufficient jnBtificntion for troubling the Society with the
details o£ those cases, that it is generally admitted that
the amount of urea eliminated is the best guide we have
to tho functional activity of the kidney ; and if this be so,
the value of these records is the game, whether the fits bo
due lo urea, or to products resutlicig from the decomposi-
tion of urea, or to waste products which ought to bave been
courertcd into uron.
Dr. Pbikstlet said tbut the HiDcere tlitinlig of the Society
wen> due to Dr. Honiiau Tor tbe gM>;iit euru mid zeitl with which
hia obserrations on ttio varying conditioiit) iu ci-lauipuiu liaJ been
conducted. It was oidy by such carprully recorded facts ifiiit the
true patholog}' of tlie obai^iiNt dineaKC wa« liltply to be i-lucidaled,
and it uM obvious tliat luuch jrct romoiued tu l>o le&raed about
it. It was ililHcidt to discUAB the jiapi-'r in all it» beariiign, but
one fact struck him particularly, va. the abiienee of thnt high
tomperaton*, ta indicated by the tiiermo meter, which had been
pointed out by writom on the Contincat m uaunlly present
during the progress of puerperal comuisions. It was bt^ld
almost ft« an article of failh in France and Germany that higti
pyrexia (specially pertained to attacks irf eclampsia, the tL-i[ipLTa>
turu rising su hi^^h in suint; CAse» a.* 43" C, ur about lOd'' F., and
inorvasiiig from the beginning ofa fatiil attack to tbc end -, while
with conviilsioua, tliu result o( gonoral urienua, the temperature
fell progri-tiiively uutil death. Wiuckel claimed Rrat to have
TirEBPCaAL SCLUMPRIA.
I
pfliiitci] nut tlie remnrkable rise ia tempernfiire during tite
paroij-sms of eclampaia : and Charpentier, in controverting liia
claim, maltea a severe attack upon him for advancing it. The
Inat-amnecl author Bka.U;a iliat Kien toarle t!ie lirst eenoun
rcBearcIiOH witli the tliermoinetor in eclaiupBia, anil after liim
]luurDi.-vili« und Butlin. Dr. IIvrtiian'H paper vaa- il suffiei^iit
]>ri)i>l"t'iiat wo were nut yet inpoaHCHBioDof all the patbologicuL facta
relating to the various forma of puerperal eclampsia, and lie had
cortaiiily proved that the iliaeaae had not a uDitbrm clinical
history.
Dr. ilooBOCsa quite agreed that there was a raried cliuical
Ihistory, OB weiL as a varied morbid anatomy, in csbbb of puerpenit
eclampsia, i'riamrily they were divided into two groufe as
eneentiftlty distiuat as npili-pB)- mid uricmic convuIeioaB, nnuiely,
i\wsu in whivh tlifrc* was uo albumen in the uriiie/and those in
M'hiL-li there was albumen, often in large qu&iitititiH. He believed
that the ialti;r group at Icatit, and pcThapa the former, might be
Ktill further subdivided, aeeording to differences in pathology.
But not kuowiiigvBt how to dittiiiiguiMh tliuse diHV'rencect, he lind
hitherto treiited too uou-albuminuriu casea na cases of epilepoy
complicating pregnancy. In nil theiie he bad Bduiinistered largo
doaes i)f broniidu of potasBinni per rectum ; la one ckbg as much
a» iiiucty grains werti giion ibis wity in viie dose, and Ihe patient
recoKrcd. Ue had luid anutiier caae with Dr. Marsball, of Ber-
mondsey, but the patient died. Kegarding the other cases ia
wliicb aibuineu naa found, t!ie aduiiiii^tration of morphia ^aa
pL'i'liaps dangerous, cspfcially wlierc tlie uriemic element pre-
VilIled^ Tlio reeenrt'h'es rt-gardiiig the tempL-rature aud ihoqiiau-
tity of u.rcii ^xeroted vicre very valuabif-, and his own experience
was that t1io temperature was raided an a rule, and in eoine cases
he bad found that it continued to rise for a few hours after
doath.
Dr. W. 8. A, GairrrTiI remarked that there were tivopointa in
the elinicsl history of thenephritiB of pregnancy (with or without
puerperal t'clampsia) about which informalion »"ii.« much ueeded.
The Qrift bad to do with thi; origin ul' the diaear-e. In what:
proportion of cusfa had there been any evidence of prc-eiiating
iicphritiH, cutiipliealiug Evarlutiun or diphtheria, for instance i*
The other was the termination of the liiaeaee. Ifow many casca
died eveiilually from or with kiiliiey diacapc? It was geueralLy
hdil, ho tbou>^)u, that the di»ea»o una teiaporary, and that ia
favourable casi-s recovery aooQ took place. In discwsg-ing the
qucation Dp. &ee bad stated to him that in bis experience very
itinny of tlieno cjisfs in later life developed eymptonia of chronic
kidooy diicoso. Dr. Uritllth would be glad if l>r. Herman could
give him any information on these points.
The PaemuiiX'r said that he thought that the theory pro*
jtonnded by BounieTille that eclamptic atlacbs raised the tem-
rUKlU'BKAL ICLAMfSU.
• )l
pemturc, wliilo uncmiA lowered it. applied not niily to B^|i8rAle
cases, but to the dilTerent elementR in the e&mtt cute. If, there-
fore, the urttmic conditiooti, tte evidvaced l>y iJimLDi«bcd KcreUoa
of urea, preponderated in proporlion to the frequency of tlie con-
vuliionn, it might be expccti^il that the Blcvntiuu uf tL'm|)t>riiturQ
would be int«rfcrcd witii. He asked Dp. Herman if tliia pHu-
ciple would explain any of the annmnliea obnerved in his casOT.
Agun, in bis fxperleitpe, it was elilefly in uiitrentcd crhus thnt
veiy murked elevation of temperature occurred, nnd chlitrofopra
or Ueudiog vapvciully coutitcructcd it. In oue auu, utitruated
until tbe (latletit was nionbuDd, he had found the temperature as
hiph M llOf.
Dc. Ukuuax, ill reply, »ai>[ that nltliuugh lie had quutcd
Itounievillc'n paper, he had not iuLi-nded l>y iloius bo lo imply
any oitiriion ue to the quosticm of priority b«tw(]^oii him and Prof.
AVinvkel, He agreed with Dr. Uorrocke that cases of eclampsia
without albuminuria were very different fniin casea with nlou-
minuris, aud lie would add that catcii in whieh tliere wan a mcrt!
trace of albumen were luile difl'crcnt from 1ho*e in which tho
urioc wa« eu loaded with albuiut;u as to become uearly solid on
boiling, MS in thu caseM now related. The oni? fraturv which all
thcHG cftiKia had io common was a diminution in the excreliun of
urea dtirinj; tbo time in which the Cilti weiv. ai'currnj;^. Thcue
caaca, bo far aa they went, did not mipiiod iIil' view tiiivt thu
cIuvatiuQ of torn peral ui-o was in pniportioii to the numhur uf the
filfl, for Caac 5, in which the fits were uoat; uuucruue, hnd uut
tho highest temperature.
ANNUAL MEETING.
Febhdaky 5th, 1890.
AiruD L, Gajabin, M.D.^ Frcsidemt, in the Chair.
Preeent — 41 Fellows and 1 Visitor.
The President declared tlie ballot opcu for on o 1) our, iiud
appointed Dr. Clapbam niid Dr. Diikiu as scrutineers.
Cbicliester (J. May, M.A., M.B. Cantab. ; Charles Heury
James, L.K.C.l'.Lond. ; and Tbomaii Kdward Pai-60u8,
M.R.C.S., were admitted Fellows of the Society.
Edward H. Douty, M.A., M.B., B.C.Cantnb. (Cam-
bridge) ; J. Arthur Hclme, M.D.Ediu, (ManuhcBter) ; and
'lliomuH Riubmund, L.R.C.P.Edin. (Qlusgow), were declared
admitted.
ITie following gentlemen were elu'ctcd Fellows of tlie
Society: — Christopher Martin, M.B., C.M.Ediii. (Mid-
dlosbrougb] ; Benjamin Wilfred Tlionias, L.B.O.P.Lond.
(Welwyo) ; aud George Porter Worauiu, M.R.C.8.
The following geutlomeu were proposed For election : —
William John Gow, M.D.Lond. ; and Aylmer Orr, M.A.,
U.B.Oxon.
64
DOUBLE PYOSALPINX.
Bj' CitaitLBS H. CArrEB, M.D.
The Epeciiuen was removed by alidomiiial section from
B putieut aged 24, married two niidalalf years, but ucvcr
prcguaut. She hnd suffered from dyspareimia and pain
for tho lust twelve months, and these symptoms had in-
t-rea)ied during tlie last six months, so tba.t she was uuablc
to wiUk any distanco, or quickly. SIib hud nevt-r had
any vaginal discharge, or pain or trouble on micturition.
The catami-nia began at fourteen ; pre-menstrual pain
uaiially lasted three to four ilriys ; worse since marriage.
Period used to last three to four days, during the last two
years it lasted five to six, and the loss was greater.
Till! husband says lie had gleet sevea yenrs beforo ho
was nian'icd, bnt was well at the time of naarriago.
On vaginal examination the uterus was found to bo
pnslicd downwards and forwards, and tbe two tumoura
were felt one on each side behind the uterus, and move*
able to Kouio extent. At the operation both were adherent
tij the peWic floor, and were shelled out with difficulty.
To the left tumour there was a wide omental attachment.
The right tube was five iuclies long, the ovary closely
attached tu it, and on cutting into it about 2 ok. of healthy
pus escaped, The left tube was about four inches long,
and eai:b was about two inches in circa inference. Tiie
putiuut tuado an uainteriuptod recovery.
CYSTIC DISEASE OF THE CHORION.
By A. K. Auai Lawuenck, M.D.
Dk, Ai;K'r Laweexcb exhibited a specimen of eystic
disease of the chorion. The patient was only two uuuths
CrSTIC DISSA^SK nr THS CBOBION.
65
prcg^iant, yet her uterus was of the wize asDally attained
at the eighth month. Tlia enlargement was due to con-
ccikled hnemorrhage and the diseased chorion. The uterus
was cleared out and the patient did well.
Dr. Anst Lawrence l«id stress on two points in the dia-
gnosis. Firstlj", the enlarged uterus is alwaja out of pro-
portion to tlie date of pregnautj ; aud secoudly, the form
of the uterine tumour is always irregular, not at all like
a pregnant uterus of a. corresponding sixe. As for trcnt-
uient, the uterus eboutd be cleared out as soon oa the
diseased condition is recognised.
CYSTrC DFRKASB (HYDATIFORM DEGENERA-
TION) OF THE CHORION.
By John Phillips, M,D.
Db. Jobs Phillips oxhiljited a portion of this morbid
product of conception. The patient was aged 42, and the
mother oE severol children. She supposed herst'lf four
months pregnant, and was certain of the occurrence of
foDtol moremeuta. She had been floodiag iucessantly for
three wcelis. Her condition when £rat seen was alarm-
ing,— oedema of the feet, legs, und bands, the pulse 140,
respirations 42 per minuto, and tho uaaal necompanying
signs of prof uflo hafmoi-rhago. The uterus extended about
two inches above the umbilicus, and no fa>tal heart-sounds
were audible. Thc> os utori was dilated to the size of a
sixpence only. Ethpr was given, and after preliminary
dilatation with Barnes' bags the whole mass was scraped
out of the ut-erine cavity. Easy recorery followed. No
albumen could bo detected, and the cederaa of tho legs
nnd hands was gradually disappearing. No truce of a
fcetns was discovered. The interest o£ the case lay ia
the qaestioQ of the diagnosis, which it was almost impoa-
voi:» xxsii. d
HJKMORRaAGE KBOM THK OTKBIWI! WOCOICS MEMBRAXK.
siblo to miiiko from plncpnte prsevift until the introduction
of the band into tlie atei-UB.
UTERUS AND APPENDAGES OF AN INFANT;
HAEMORRHAGE FROM THE UTERINE MUCOUS
MEMBRANE.
By C. H. James.
Me. C. H. Jamis showed tlie uterus and appendages
of a ctild aged 5 daye, wlio, ou the day previous to death.
Lad a Banguineous discharge from the vulva. Tie child
wati weakly and prematare (eight inouthsjj and took
nourishment very badly. There was no Bwclluig o[ the
breasts and no jaundice. The la-bonr had been natural
and easy. On laying open the uterus »t the post-mortGin
examination, the mucous membrane of the body was red,
swollen, and covered with bloodj but the cervical mncoQS,
memhrane appeared healthy. No digease was detected'
in any organ, except the liver, which waa pale and
yellowish in the centre. A discharge of blood from
the genital organs in new-born children has frequently
been noticed, but it is rare fo get an opportunity of
domonstratiug its source from the uterine mucous mem*
brace.
Dr. Ccllisowobth eaid that some yenre ago be took great
trouble to collect all tlie case^ lie cuuid find recorded of Iwmor-
rliage from the goiLital orgaiii of the newly-botn femnle child.
He had embodied the results in a paper published in the
'Liverpooi and Manchester Medical aud Surgical Reports.'
This ciLse, tbererore, wtts of special interest to him, tlie more so
as it ntTorded a rare opportunity of ascerlaimug by inepectioD
the source of the blood. Ho far as lie know, the only other in-
stance in nbicb there had been a eitnilnr opportunity waa one
recorded by Billard. In thnt caae also the eeurce of the bleeding
was the iuner eurface of the body of the uterus. The reason of
the rarity of potit-iiiartein exauiinutioDa was that in the groat
nTKSirS SHOWIKO PUCRNTA ?H£VtK.
07
nujurity of casva this «itcv-iioa naa quite inaigni Scant. Ko was
glwi a microscopic eiuniaation wa« to be maAs.
Dr. Qkubhut Spbkcicb bad only seen one case of heemorrEiQge
from the li»ing iutaut'a VAgina, nQd the case recovered. He had,
howeTcr, several ttmeH met with congestioD of the uterine mucous
nvmbrnne in stiil-born childrvn, as in this apecitnen. He had
olio aeoQ bffimorrhaco into the uiucoua niembruue of the body
and into tlie subpentoneal tisoue aroiiad the uterus.
UTERUS SHOWING PLACENTA PR.^\t:a.
By A. H. BouiNsoN, M.D.
(Ooinmunlcateil fcy C. J. CwLLiieowoitiH, M.D.)
i)R. RoBiNsoH exhibited a uterus with placenta praavin,
reuiored from thu body of a ^rl aged 17, wlio liad
been ailing for several days but concealed her condition
from her friends. On the day of her death she was found,
early in the morning't coTered with blood, but denied all
kuowledge of ita origin, and refused to be exumined hy a
mcdicul man called iu by her mistress. 8he was then
rCEQOTOd to the houeo of a relative, and later to a general
hospital, where she remained some time, but again refust'd
to be e.-camiued. When first seon iu thooveuing ahe was
perfectly bl&uched, there was no pulse at either wrist, the
heart-HonndH were feeble and faltering, and the girl was
qaite unconiicious. A va^lual examinatloii was made, and
the 08 uteri found to be dilated to a diameter of an inch
and a half. Immedi)ttety within the os the finger eu-
conntored a spongy msds, through which the foetal bead
could be detected. No hDCmorrhago was now present, but
the girl's clothing was saturated with bleed. There was no
Mcopo of amniotic fluid, the membranes being intact, and
uterine contraction being in abeyance. It was proposed
to perform tmnsfusion, but before that could be effected
the heart ceased to beat.
68
CTBBUS SBOnma FUC'KKTA PK£TIA.
A necropsy was made two days later, when, beyond tlie
most marked anffimia, all the org&ns appeared perfectly
normal. Tbere -waa a Bmall amount of very soft black
clot ia either ventricle of the heart. Openings were made
in the iliac veins, and they wore f onnd empty. On opening
the abdomen tlie pregriant nteras wae seen to extend ap-
nards to within two inches of the ensiform cartilage. A
vertical incision was mudo in the antenor wall, atid a fully
developed fcctng extracted. The nteraa being then re.
moved from the body, it was fonnd that the placental at-
tachment occnpied the whole of the auterior wall, ex«
tending from within an inch of the fundus above to the oa
helow. A free portion of its circumference, some two
inches in extent, was found projecting through the dilated
OS. On this free edge of the placenta existed a rent
an inch and a half in length, the mombrancs being
separated for some diettince aronnd. Tbix)ugh this rent
the reticulated Kubatanco of the placeuta could be eeeu, and
from this situation prolonged hsDmorrhage had doubtless
talcen place. The pelvis was well formed, and no impedi.
ment to natural labour existed. A placenta succenturiata
was present.
The specimen was referred to a committee consisting of
Drs. PJayfair, Cullingworbh, and Cliumpneya.
60
URETHRAL DIVERTICULA.
By Amand EoutHj II. D,
(iteceivtiii NoTeuib«T titb. 1880.)
{Abstract.)
TuuSE cases qE urotiirarl divtirticuU aro I'ola.led, and reEereucns
to otberB made. The literature on iiiQ subject, though datiug
from 1847, is soaut}' and Bca-ttei-ed.
Tbe gynijiloms are progresaivtj discomfort and frequt'iicy o£
miotaritioii, dysparemiia, and tit fovmatioa of a awellii^ which
tiffitua lit the vagiuad ori&cu. Pressure upon the Hwclling
causes Ihin, offensive, irritating I>U3 to pass into and out of the
iirethni. Cases are recorded ehowiug that if thetjc divertii^uliL
are left uotruatwl, retrograde changes uccur iiloug the urinary
tract,
The phyiieal eigits are (ineqniTOcal, diCFeriug on the one hand
from disloi^atioii of the nrcttra, and on the other baud fro^m
■imple dilatation of the middle third of the inferior wall
(urethrowle).
The iliverticitluni is essoiitlally a urinary poucli or cyst com*
municating with a urethra of normal calibre, uaunUy in ila
middle third, Ly nu orifice relatively narrow.
The stiolotfy seema to be — 1. CloBure of the ducts of pre-
exutiu); urethral glauds, rvteutiuu-cynta reituhin^. Suppuration
aod tilc«ra.tiou inl« the urethra by a, small, often valvulur liole
follows, anil the inflaininiiitioi] ia kept up by urine trickliog iutu
tbo MM! at cac'h act of micturition. 2. Blood-cysts which have
paued through Rimihir changes. 'A. Thia formation of pseudo-
cysts by injury to the urethral floor during labour or inntru*
muiitation.
FregaaQ«y» vitL its increased local actiritr, seems usuoily to
?0
UKKTHKAL DIVEItTICUIJk.
iaduca tlie foriaatioii o£ tbeee cyete, and iiariilriUou ai)]>u>irii to
be often the immediate cause of the >'Uj>ture.
The treatment is injitiily surgical. 1st. Where uretkriiU nr
c^stittB exists, the cjfBt-w-a.ll eliould be dissei-ted out, and cut off
close i^) thi! wrutbra, Fiud tlie viigiiiul wouml Left open for ilruiu-
age. 2iid. Wltere the vri-tt-arif jjaeemi':!! are healthy lUec^vst should
bo diseeo-ted out, the opening into the urethm enlarged to allow
diainage, and the vaginal wound at once closed. In either caao
the ui'ine should be drawn off till union is assured.
Three eases have recently come under observBtiou at
bbo Hnmaritan Free Hospital, and as tbej appear to be
not infrequent, and yet have been rarely doscribed, I h&vo
veiiturod to bring thorn before this Society, hoping to hare
light thrown opon their (etiology and proper trcatmont.
These diverticula occupy the arethro- vaginal soptiini,
and commuuicato with a urethra of tiormal calibre and
position by a small opening in its £aor.
Roughly speaking, the rixjviptoms are progressife discom-
fort and fi-e(]Uency of micturition, tlie appearance and
growth of & tender lump projecting at the vaginal orifice,
passage of thin irritating pus, cither at the end of mic-
turition or on pressure, and auoiier or later cystitis, &c.
The physical tfujna are aB follows : — Per ■caffinara n
rounded, teador, touse swellbg is found in the urethru-
vaginat septum, opposite the middle third of the urethra.
Its gmoothnesH and elastic hardness are characteristic, the
rugHQ of the mucous membrane over it being oblitcirated.
In some cases the mucous membrane move& freely over
the underlying sac, in others it is adherent by inflamma-
tion. A sound paaaed along the antenur wall of the
nrethra goea directly into the bladder, proving that the
case is not one of urethral dislocation.
As proving further that these cases are not simple dila-
tations of the middle third of the inferior vrall of the urothm
(simple urethrocele), it is found that a large-Bixed sound
will not enter the pouch, but will pass on into the bladder,
whereas a snoall sound or probe will find its way through
IRAl UIVSBTl
71
the narrow opening (which is often valvular), if it be
pftssed along the posterior wall of tlto nrothra. The exact
siee of the opening (usually from 4 to 8 Euglish cathoter]
is ancerlainGd Ity a. gradaated bulbous sound.
With a bougie Ijing in the urethm the sac is folt to
be quite distinct, and even wLen eniptioil by proseure it
remains a distinct tLick-wallod cyst. Wbeu full, thcBO
c^'sts vary in aiKC from that of a pea to that of a heu'a egg.
After being emptied, it only partially rDliila at the next
act of mictarition, taking »is or eight hours to becomo
tcnso by exudation from ita own lining inembrane.
'^-■li.
A
The first of llie throe cas&s wbich have come under my
notice was admitted into the Sauiaritao. Free Hospital by
72
ORKTSIUL DlTXKTICOU.
Ifr. Malcolm, under tlie care of Dr. Percy Boolton, in
February last, and he kaa kindly placed hut Dotes at uiy
disposal.
The patient was a Diarried multipara, aged 33, whose
cfaie£ pelvic trouble was dysaria.
Examination revealed granular endocerricitis, and a
urethral divorticulum the size of a marble. Dr. Bonlton
treated her by urethral suppositories of lead and blsmnth,
and with medicines, for three weeks, with no benefit, and on
Hareh 1 1th dissected oat the cyst -per vngmam, using ouo
^ut sutnre to draw the vaginal wound together, which was
iiot otherwise closed. The nrine was drawn off regolarly
by the narae, and the wound had granulated up in seven
da.ys, by which time no pus could be expressed from, the
urethra. She is now quite well, all cystitia having abated.
The sac, when removed, had a rough fibrous capsule
firmly connected with the adjacent tissnes, and was not a
true cyst. It contained dark red, fleshy trabeculre, sag-
geeting organised blood-clot, and had no smooth epithelial
lining. Dr. Percy Boultoa thought that the cyst waa
orig^inally a blood-cyst, the result of injury during partu-
rition, and that connection with the urethra wns dno to
suppuration, Inflammation being subsequently kept up by
access of urine.
Cask 2. — h. T — , aged 40, married twe)ity-two yearsj
ton children, last fourteen months ago, March 2l&t, 1889.
Complained of dyspareunia for three or four months, and
the formation of a patnfnl lamp at the vaginal orifice.
Had iuflumuiatiou following pod<c version at la^t confine-
ment, but beyond pain in left ovarian region noticed
nothing till ten inuuths afterwards, when the dyspareunia
supervened. On e?; ami nation, sigiie nf old perimetritis
were present, the fundus uteri being drawn backwards and
to the left. A urethral divorticuhim the sise of a small
walnut was found, containing extremely offenaive thin pus,
having physical signs as above described. On Juno 7tb,
Absisted by Dre. Pi-tukett and Kutherfuord, I dissected oat
CRBTBRAL DtVBRTICDU.
73
tto Cyst, wbicli comtnutiicated with the nrethra by two
upeuings. Those were united along the Qoor of the ure-
Ihra, the vaginal wound closed by six wire suturctj, and
a retaioinf^ catheter iatrocluced.
The wonnd beAleil, but a pinhole opening' remained at
thcADtcrior oiid of the incision, which, however, the patient
declared cnnsed her no inQouvcuioiJc<.', and shu refuaod to
have it closed. She is now frt^e from all pain and dis-
comfort.
Dr. Ruthcrfoord kindly examined the sac for me, and
foand it, iiuliku Dr. Honlton's, with no trabeculie inside,
ADd with a smoothand somewhat glistening out«ide surface.
Oa aectioQ it was mainly couuectiYe tiesue, with evidenco
of an inflammatory process on its inner side, opou which
no epithelinm was traced.
Cabs 3.^ — M. K — , aged 27, married three years and
a half ; one child, two years and a half ago.
October let, 1880. — CunipIninR of a teuder Bwtlliuf^ in
tlie front passage ; pressure upon it oauises puiu and «
discharge of irritating matter ; for a time, however, after
the sac la emptied the gnawiagj throbbing pain, whicli is
otherwise alwayii present, is relieved. She had (jnly
noticed Ihe lamp a month, and says it followed a feverish
attack, with ninch local pruritus and scalding during mictu-
rition, which latter symptom she had noticed oS aud ou
siooo hor confinement two aud a Imlf years ago.
The physical signs of the diverticulum were idcnticid
with those already described, tho opening into the urethra
being about the size of a 14o. 0 catheter. EtTorts
were made to apply cauhiicR to this eavity by dilating the
front, part of the urethra; but, tliis failing, ! operated ns
before, removing, however, only a portion of the cyst-wall.
Thr woman was directed to pass water in the gouupoctoral
position, and left the hospital cured ou the twentielli duy.
But few rcfi'i-OLcos uru made to these cases in litBratuit'.
Parish* of Philadelphia quotes Cheron'sf views, and
* Ufejov*** * Annual of Uiiivvnul Mod. Science*,' lol. tv, 1888, p. 164.
t ' aat«lU! dea UApiUui,' 1SH7.
74
UKKTHIUI. UlVKKl'ICUU.
Jonks* aJopla tlieni, consiilering these cases to be variefciea
of urelhrucelo, which should bo divided into two cIbescs :
1st, simple localised dilfttntiou.of tlie middle third of the
inferior wall of the urethra; and 2ud, a urinary poucli
cnmmunicatiug with a urethra of norrniil oahhrO by an
orifice relatively narrow.
These three observere riow these diverticula as being —
(I) congenital; (2) caused by union between the uretlnu
nnd n pre-existing non- con genital vaginal cyst ; or (3)
determined hy a, limited touring of the upethral floor
during labour.
In 1869 Dr. Priestleyf described three cases, which he
thought were doc to distention of sebaceous follicles.
His iirat case, and possibly Dr. Hickinbothara's described
below, are the only recorded examples in which the cytstH
werediscoveredbeforeniptureintotheiirethra had occurred.
In both of these caaes, howerer, rupture into the urethra
occurred during the impending labour, and wo may assiirao
that thiB 13 the coiiioion history iu the majority of these
urethral diverticnla. Dr. Prioatley'a secioad case ia also
iutereating, for sebaceous material was discovered passing
from the cjst. The opening here waa in the middle third of
the urethra, but waa evidently valvular, pressure upon tho
cyat causing the contents to pass backwards into tho
bladder. WestJ refers his readers to Huguier'aJ work
published iu IS17 for notes of some of these cases, admit-
ting, however, thiit he was then (I87i>) not familiar with
them himself. I cannot obtain access to a copy oE
Huguier's paper.
Dr. HickinhotliamjII of Birmingham, pablishes a very
interefetiiig case which occurred in a uullipara, daily ox-
poctiug to be confined of her first child. Cephalotripsy
was porfornied because of a rigidly contractod cervix,
* ' MiiDt/* Sjgtcin of QyniDcolcg7,* voL II, t&S8, pp. 476,490.
+ ' Brit. Mod. Jtmrn..' 186i). vol. i. p. 6.
t Wnt and Duncan 'i ' DiioniM of Women,' -Itli edit., 1879. p. 029.
S •M<inoirBB<l«l«Sooitft^deCli!riirgie de ParU,' vol. i. 1847. pp. 326— 394.
II ■ lirlt. Mv<i. Jonrn., 1882, vol. i, p. 613.
OKBIHEAL DIVKiniCULA.
75
and i)nhse<iiieiit events seemed to ^how tlinl; tLe siiu
then ruptured into the urethra. At all events tlie cyst at
once began to grow mpidlj aud becoino tender, presuta-
■bly by the entrauce of urinu causiu.^ more mflaninuttion,
aud OQ the Icuth duy ahcv labour tho c^'st ruptatcd also
into the ragina. At a subsequently successful oporntion by
LawsOD Tnit, tho valvular opening into thi? urcthnt, of the
aise of a hempseed, wns well sevn.
Law&oa Tait* has aleo described four other casus, ouo
in 1875, the others in 1885, He thinks these cysts may
bo congenital, like intestinal diverticula, or the result of
onion between the urethra and a cyst of pathological origin.
Englisch^t of Vienna, has seen such cysts at birth.
Sautessont arguiug fi-om a case eecu in 1801, thinks they
aro duo lo injury from liibour, or to clumsy catlieterisa.-
tion, or to rupturo of simplu vaginal cysta.
Duplay^ has collected six cases, one of which (Gillette) [|
is a case of simple iirfthrocele, imd two others doscribod
by Foueher^f and G. Simon** contain no nt'w points.
Very few modern Knglish text-books of gyniocology
make mention of these cn8o<;, and, etrange to say, ncitht-r
Htnioei iior Skene alludes to any oilier form of urethral
dilatation than tho siuiplu urelhrooflc, though tlioy cuIlx
largely into genito-urinary troubles, one case of peri-
urethral abscess bt-ing mentioned by the latter.
Those who have studied tho anatomy of the urethra
describe many varieties of glands, closui'e oi whose ducts
Tvould lead t-> the formation of rctention-cystu.
Thus Littre's glands, which are little more than mucous
uembrave reduplicatioua, are doecribed as being about
twenty. five in number, running parallel with the urothral
■ ■ Un««t,' 1S76, vol. il, p, 63S ; and ■ Brit. Mcil. Jonrn.,' ISKS, vol. i,
p. 982.
■f • Wioner muH. PreHne," 1881, a. 599.
J 'NoHlbktBitJ. Arctir,' vol.xvi, IBS*.
I ■ Arcbiv. Ucu. du Mo)..' vol. rii. 1880.
II 'L'Uiilon MWiwW April 13lh. 1873.
Y ' Uonileiir d<« llflpitMni,' I8S7, p. 758.
** ■ llocualwUrift fur (lobnrtilc.,' xxiii, «. 215.
76
CtRSrBBlI, ClTERTICCTLi..
floor, and opening into its anterior half or two thirds hy
apertures admitting a bristle.
The foIlieleB of Morgagni, again, aro numerous rnnall
racemose glands opening by minute ducts at right angles
to the uretliral floor.
Skeue^s* ducts, which appear to be the efferent canaU
of Mftx Schiilier'st glands, are two in number, run parallel
to the anterior third or half of the floor of the urethra,
and open into it just inside the meatus.
Any of the above dncts or glands maj become retention-
cysts by closure of their oritices by urethritia, peri-
■Brethritie, or even accidental plugging. As a result of
Buppuration or rupture the cyst then opens agniu into the
urtithrn, and tho iuOammatiou is kept up by urino fiudiug
access to its cavity at each act of micturition, and, owing
to the &ma!l and often valvular character of the oponiug,
the distention of the cavity increases.
As these diverticula appear to be always opposite the
middle third of the urethra, it seems improbable that they
can he due to occlut^iou and distention of Hkeue's ducts
whicli are oppoaite the anterior third, unloss, as Mr. Albau
Dorant suggests in his reriew of Dlnnd Suttou's^ work
071 Gartuer's duct, Skene's ducts are the anterior termina-
tion of Gartner's dncts. Though Gartner's dncts are
doubtless reHpoiiaible for vaginal cysts near the cervix.
Max Schialler,t Fischel, Dohrn, Rieder, || all deny that it
ever reaches the urethra. Mas Schuller*H glands, from
which Skene's ducts lead, seem to he the most likely
urigin of these retention-cysts.
Blood-cysts, as in Dr. Percy Boulton's case, may be
another niodo of origin, and injury to the urethral floor
an BUggested by Cheron, Saiiteasou, and others, may also
be occasionally productive of a paeudo-cyet, whose sym-
• 'DiBeiMs rf Women,' ISStlj ji. 516.
i ' Eiu Deitriig tat AnBtoroio <l<-r ivpiblir.liPii HaTUrUlirc,' 1883.
J • Lond. Mca. Ilec,; 3H86, p. KIH.
I * Amrricitn Jnurii. of Olstutrics,' vol. xlll.
II • Loud. Med. Ibio.,' i88C, }i. 8S,
UB^THHAt DIVEHTICDIA.
77
IB and pTiyBicnl signs may greatly resemble tlioRO of
trco retention -cysts.
Pregnancy, owing to greater local activity, seems to be
a starting-point for the formation of the di7erticula, and
the impending labour may eufiice to canso rupturo into
the urethra {Priestley's and liickiiibotham's cases), thas
anticipating the slower effects of a subsci^uent Guppuration.
As the ietiology of tbese trases is so diEtinct from that
of simple dilutation, it seems a pity that both should be
grouped under the one word nrethrocele.
The treatment of these diverticula has been varied. Bo
long as the cysta are not iD conituuuicntlon with the
opethra thoy can he treated like Bartholini's reteutiou-
cysta, bat when nrine is obtaining intermittent entranco
the problem is more difficult.
Palliative melhods have invariably failed. Mr. Alban
Dorou* has kindly referred uae to Saiitesson's. eaao wliiuh
occurred in 1861, which seems not to have been described
till 3884.t It occurred in a widow, whose dysuria,
prarituH, and vaginal swelling dated from a con^nemeiit
twelve years previously.
The phyeical signs differed from the typical iu only one
respuct, pressure upon the swelling i>er viifjina»i, cniising
its contents to go backwards into the bladder. After
fonr years' trial of palliative treatment, pressure, caustics,
SiC, an elliptical piece wan cut from the vagintil wall, and
from the wall of tho diveriiculumj the wound beingunited
by sutures. Some sloughing occurred, the wound talcing
five weeks. to heal, and four years afterwarcls the sac again
enlarged, urethntis, cystitis, and nephritis supervened, the
patient dying six years after the failure of the first ope-
ration. Santeaaon now states, after tweuty-thr^e years'
interval, without apparently meeting with another case,
fchat in any future case he wonld remove the wholo diver-
ticuluta, suture the margin of the wound, and keep a
• ' LoiiJ. M*^. Rw.,' 1885, p. 08.
f ' Norditkt mti, Atubiv,' voL sri, ISIiH j ' Schmidl'a J«lir1>ucli«r,' cciii,
]MTi ia, art, 479.
78
URETHRAL niVKBTIC
cathe-ter in intu till union was complete; and t!iis metliod
was adopted with success by Lawson Teit in his four
cages. In 1868 Dr. Priestley,* in conRulta.tion with Sir
James Paget and Sir Sfiencer Wells, proposeil to pass a
seton through a urethriil diTerticuluni for its ohliteration,
and. If this proved iueffectual, to lay it open per iwginnm.
The patient, liowevei", sliraiik from any surgical inter-
ference, and her subsequent history is unknown.
Cheron,t in 1887, advocated Blitiing' up the urethra
from the orifice of conimuDication to the meatus, and the
one case ho saw and thus treated wan cured. From the
experience brought by all these cases it seems that there
are two ways of dealing surgically with them, and that
if we desire to prevent such retrogrBBsive changes aa
occurred in Sontesiion'a case, we should promptly adopt
ouo OP other, or some operation.
1st. Where uruthritis or cystitia already exists the cyst-
wall Hluiuld be dissected out, and the vaginal wound left
wholly or partly unclosed to allow of free drainage. In
the rare event of niiiou not occurring, a sccoudary ope-
rution would bo roquirud later. This was Df. Boulton'a
method of operating (Case 1],
2ud. Where the urine is normal, and the urinary pas-
sages are healthy, tlie cyst should be dissected out, tlio
opening into the urethra enlarged to allow of urethral
(Irflinage, and the vaginal wound at once closed with wire
sutures, which should not enter the urethra itself.
Till union is caraplete, the vngiua should be kept asaptie
as far as possible, aud tht) «rine should be drawn off
either ut rifgular intervals ur by a retaining cathettr; or,
as was adopted in my second case, the woman may bo told
to pass water in the geuupectoral position.
In dissecting out the diverticulum the presence of a
l&rge bougie in the urethra ia Lelpfol, and the contents
of the cyst should not be pressed out lest it become tiaccid.
Before the sac is separated from the urethra it niay bo
• ■ Brit. UtHl. Joorn.,' Ifm, vol. i, p. a
t ' Cla»ttc «1>-it HOpiUvV lsa7i
QRI3THRAL DIVERTICCIA.
79
JnOlMd, and after its contents have escaped the Rtnall
opening into tbe urethra can bo woH seen.
In my second ciise I rumoveil only s, portion of the sac ;
but though the cure ia complete, it seems safer to disaect
oBt the whole cyst-wall.
Dr. BSAXTOK Hicsa uid that iu tlio couruu of hit practice he
had Been five coac^i of Lhe kind ; iu one tlie cavily was lilled witb.
pboBpbatic concretions. Kw had truuted Ihem 6y vpaaing them
Jreely from the vagina, keeping the openiug free till ihe urethral
opentng closi^d, which he fouad to occur at'lvr a little tiiat*. Hs
thought, however, that tho [>!Bn recouiuioinled by the author u£
thp p&per was more precise.
Dr. Uesmav thought that the title of the paper would hare
more currectly indicated iu contentti haii it been ^' injiamai
urothral divtrticala." These diverticula, evea when convortod
into rirtentioii-c>(ttB by cloeure of their ducts, caused no ayni-
ptomB nuch as Dr. Kouth hitd described until they became
iBBatned. He thought thut cysts dischurging fatty matter and
opeuiuj; into the urethra were probably dermuid. ] a the ' 'i'niuci>
actions ' for 1S80 h« had described a case very similar to uue of
thoia related in the present paper, lie had reported that citao
under the title " abevcea of tlie ureliira," a term which he hud
uaed a» not implying a]iy theu'ry of uausation, The interior of
the cavity iu tiiat case uatt ra;;gcd, nut smouth, Lilce a cjat-wall.
Tliis waa also observed in oncol Dr. Ituuth'H casea. Dr. Kcnnan
had nuggested that the coudittoa might have been a result, of
ehrouic cougcxtiua of the urethra, such hb had heeii deacrjbed by
Sir Charles Clarke, and after hiui by Dr. West. This condition
was especially freguoot iu preguoucy, and he ubaerved that
Dr. l£outh had commented un the Irecjitericy with whieh the
suppuration opptared to have been induced by pregnancy aud
labour. Dr. Kouth attributed it tu iujury duriug inhour, uudhu
(Dr. Herman) thought the prcHxure Huistaiiied duriug delivery
would be more likely to briug about uuppurntiou if the cougett-
tion di-ecribed by Sir C. Clarke had been present befuredclivery.
The word "diverticulum" was usually employed to denote a
communicating cavity du6 to a cougeuitaL peculiarity of struo-
tarf, and iu thai sense of tho word tlie cases of abscess opening
iute the urethra, to the description of which in the abxtroct tho
figs, i! aod '6 wto pretiied, were not true diverticula. They
could only be called diverticula in tlie same aeuse aa a pulvio
absoeas opening into the rectum could be called a rectal diverti-
calum. Dr. Houth's paper was a valuable eouCribuLiun to our
ItDowledge of the subject.
80
USSTRRAL DTVERTICUL&.
Dr. M. HAMnFiELD-JoNES Jwclt upoa one method in wMcIi
those uruthnil diverticula, might originate. Ue hnd sIiowq at u j}r«-
viouB meeting oftho Society two small cyata which lie had removed
from ibe vagina of a patient who had been Bent to bim complain-
ing of a cyatocele. The tno ey&ta wore Hitunteii bennatli tho
floor of the urethra, and during the procesa of removal were
found to h« HO clone to the floor of that canal that it had been
difScult to avoid woundmg the urethra, iu the operation. Had
they not been reniuved, these cyatn would probably have opened
into the I'tinal of the urethra as their growth progressed, or if a
labour bud supervened they would probably have suppurated
from proseure nod eHliiblished a cemuiuiiicatiuu with the urethra.
Id eitlier caae a ao-Called urethral diverticulum nould have beeu
formed, and, by the irritation caused through the adtnissioa of
uiine, hftve given rise to syuiptoius rendering an operation
ueceasary.
Mr. Alban Doran believed that the cotidition deacribed by
Dr. Amand Bouth could well arlBs Irom one of at leaat two
soureea. The diverticulum might origioa-tep in a cyst or in eome
chauge in a gland or ila obstructed duct;, fo-r c-yBta certainly
developed near the urethra, and glanda undoubtedly existed in
the miicous membrane of tbnt canal- On the other hand, the
position gf tbe urethra aud the uhyslcal fonditione tc which it
was exposed allowed of protrusioiis uf the mucous ineinbrane.
In order to be certain about the prcciBe character of urethra!
cyotB and gUude, tho adult urethra should be studied micro-
BCflpically. Hitherto writers on those strnfturcs hnd relied too
much on liomologios, and on puthologieul and rnorpboLooical
theories. Qucstiutis about Gartner's ducts and glands Wliich
uiiglit be homologuea of tho vesiciilffi Beniiiialna in the male wore
very interesting, but not to tbe purpose in the present diai-uft.
eion. On tbe ether hand, a urethral diverticulum niiglit have
been a diverbicalum from the lirat and never a cyot. It then
reeembled the " distention diverticula" of the email iiitott-
tiue to which Mr. Doran referred in a paper in the ' 'IVansac-
tiona of iho PathologicaE 8oi'ietyof London.' vol. xxix, p. 122
(ece lii. Hilton F;igge, ibid., vol. xxvii, p. 146). Poucbea of
mucoUB membrane prutrudicd between deEiciencies in the muB<
cular coat of the intestine. Tho urethru was etill inure liable
to an homologous condition, since its niuoculir coat might be
damaged in the second Btnge of labour.
Dr. Ama:(ii Boi^tH euid, in reply, that he could find no word
better able to oxpreatt all the forms of these cyHts than
" diverticulum ;" and, in reply to Dr. Hennao, he thought tb&t
the moment urine obtained access to the cyst inHammatioa
ensued. Perhapa other origins of these cyats were from a sub^
scrouH follicle at from a dermoid cyat, aa had been stated bv Dr.
Priestley, lie thanked Dr. BraxtoD Uiuks and Dr. Uaudfield*
UB1THIU.L DIVKRTICDLA. 81
Jones for their notes and early history of other cases. He had
operated on a fourth case Buccessfully since the paper was sent
in, in which cystitis and pyelitis bad already occurred. In this
case, owinff to the purulent urine, be had only partially closed
the vaginal wound, so as to allow free vaginal drainage, and the
wound was quite closed in ten days.
VOL. IXXIl. 6
Anncai, Mbetino.
Thb audited balauoe-eheet of tlio Treasurer (Dr.Hermon)
wita road.
It w»s proposed by Dr. J. Wait Black, setoutlfd hy
Dr. BuxALL, audcarvied iiimuiinously — " That tlie audited
report of the Treasurer jnst rend be received, adopted,
uud priuted in tLe next voliitue of t!ie ' Transactions.' "
TIio report of the Honorary Librarian (Dr. Horrccka)
ivas then re&d.
Report of the Honorary Librarian ftrr 1889.
" Duriug tlio paet year 134 volumes have been uddcd
to the Library. These are mndo up of 45 booka and 15
tracts (odd vol.) given, and 20 books and 30 tracts (two
vols.} bought. The penoJicaia make 57 volumes. The
total number of books iu the Library now BmountH to
4138,
"PiTIK HOEROCKS."
Dr. Dbakton Hicks, after congratulating the llonorary
Librarian on hia report, expressed n hope that the Fellows
would koop in viow tho collection of engraved portrait-s of
past 0bstctriciaii8j iiud add to it as opportunities occun-od.
It wus moved by Dp. Hicks, seconded by Dr. Montagu
Hamdfikld-Jones, and earned — "That the report of tlio
Honorary Libriiriau be receivtid, adopted, and printed in
the * Transactions.' "
The report of the Chairman of the Board for the
Kxamination of Midwives (Dr. J. Wutb Black) was then
read.
ALtEKATlON OV hLVTB.
lUport of the Chairm-an of the Board for the ExatninaLiMt
of Midwive.a,
"The candidates for the diploma of tho Society still
continue to iucroQse in niimber everyyear. In 188!) they
aiuountod to 170, of wliom l-tS pasapd, 27 failed, including
2 Bbsent, or 158 pec cent. In 1888 there were 149 candi-
dates with 14'7 per cent, of rejections. The total number
examined since 1872, when the Midwivcs' Diploma was
first instituted, np to the end of 1889 has been il2U. Of
(hesei 761 have obtained the diploma and 154 have failed,
or 16'6 per cent.
"J. Will Black,
" Chairman."
It was propoaod by Dr. Wimiam Duncan, seconded by
Dr. Cleveland, and carried "cm. con. "That tlio report of
tho Chairman of the Board for the Examination of Mid-
'Wivee be received, adopted, and printod in the ' Traueac-
tious,' and that the best thanks of the meeting be given
to Dr, Black."
The following alteration iu the Daws was put froai the
Chair and carried ; —
Caf. V. — Of the contribotions or Fellows. In Sect. 3,
itmtead of " Fellows wishing to compound for their Aunual
Subscriptions may pay a Composition Fee of Ten Guineas,"
to sulslHfite " Ftillowa wishing to compound for their
Annual Subscriptions may pay on adtniasiou a Coraposi-
tiou Fee of Fifteen Guineas ; after Ten Annual Payments,
Ten Guineas; or after Twenty Auaual Payment*, Fivo
Guineas."
The result of the BuUot, the ticruLineers having pre-
sented this report, watt declared by the President as
follows :
OfflCEBS AHD COCNCIt.
85
Trefn3enL — Alfreil Lewis Galabin, M.A., M.D.
Tice-PifJiideittg. — Percy Boulton, M.D. ; Francis Henry
Chanipneys, M.A., M.D. ; Arthur Guy Eltirgton (Deputy
Sorgeon-General) ; Thomas Crawford Hnycs, M.D. ; Evau
Jones (Aberdare) ; A. E. Aust Lawrence, M.D, (Clifton).
Treaatirer. — G. Ernest Herman, M.B.
ChairmoK of Hie Hoard/or the Examinalioit of Mtdzoivcs,
— James Watt Blaek, M.D.
Honorary Seerelfi-nes. — Alban Doran ; Peter Horrocks,
M.D.
Honorary lAbrarian. — William Duncan, M.D-
Other Mfmbem of Council. — TTionias Edward BowTcett ;
Hobertnoxall, M.D. ; Albert Clmrles Butler-Smythe ; W.
Radford Dakin, M.D. ; S, Houston Davson, M.D. ; Henry
Gervis, M.D. ; Robert Alexander Gibbons, M.D. ; Frede-
rick B. Hiillowes (Redhill) ; Edwin Hollings, M.D. ;
Henry Ambrose Lediard, M.D. [Carlisle) ; Heury Colley
March, M.D. (Roclidale) ; Richard Henry Milson, M.D. ;
Oliver Cftlley Maurice (Reading) ; Thomas Cargill Nesham,
M.D. (Newcnstle-on-Tync) ; Edward Jfttnes Nix, M.D. ;
John Bnptistc Potter, M.D. ; Herbert E. Spencer, M.D. ;
Harry Speakman Webb (Welwyn).
The President tlien delirered the Annaat Address.
ANNUAL ADDRESS.
QsHTLEHENf — TIiB past je&T h&s heou oyontful in the
history of oar Society by the termination, in it of out long-
aUnding custom of holJing oar meetings in the rooms of
the Royal Medioal and CUiirtirgical Society at 53, Bprnera
Street. That we are still passing throngh a tmnaition
period is ehown by the fact of our being now present in
^^his Library to hold our Annual Meetiiig.
It is now eight years since the Library oE our Society
was removed from the roams formerly occupied in Regent
Street to thoae in which it now is. Ky that removal we
gained more spacious and coarcnient accommodation for
our hookS] and we gained also the advantage of having
our library next door to our place of meeting, and to tiu
library of the Royal Medical and Chirurgical Society.
We did not gain anothoi" advantage which at the time we
had stipiilatud for, namely Mocarity of tenure undera loaso.
The originBl holder of the ground lease having failed to
fulfil his engagements to hia landlord, the lease for which
we had made a formal agreement was never granted ub,
and from t!mt time to this we have been annual tenants
merely.
It was under these circumstances that, through the
removal of tha Royal Medical and Chirurgical Society to
Hanover Square, we lost the coiiveniouce of the proximity
of the two hooses. In following that Society to its new
abode, so far an regards tho use of the meeting-room, it
was evident that wo should giiin a great advantage if wc
could obtain also a library in tLo same house, and thus
secure the honefila of that more favoured locality, both for
our meetings and for our library. Your Council has been
for some time engaged in negotiations for this object with
the Royal Medical and Chirurgical Society, and I have the
A!iSUAL ASDRISS.
87
pleasare to aunonuco tliat these negotiations are now prae-
tically complete^ some minor ]ega] details only not being
finally decided. Wa may cheerfully bear, therefore,
whatever inconvenience may have been felt in holding the
present and the last few meetings in tliis library, in look*
ing forward to the permanent gain which is shortly to
follow,
Wc shall, in future, have a larger and lietter arranged
meeting-room than formerly, as well as a commodions
room adjoining for exhiljition of Bpecimens. Wo shall
have two good rooms on the first floor for our library,
which will afford greater space for our books than wo at
pre^nt possess, and so allow room for progressive expan-
sion. Arrangements have also been made for the use,
in addition, of a waiting-room for tlte midwives at our
qnarterly midwives' esauiinationa, at which, owing to the
aoDually increasing aumbt;r whicli present themeelves,
mnch iciconvonieDCC has been feic in our present premises.
We ehall have, in addition, tho EDcurity o£ a twenty-one
years' lease, and we shall have the benefit of the electric
light, both for the niocting-rooni iind for the library, and
thus shall be exempt in fntiiro from the injurious effect of
gas upon oar books. Naturally gome increase of rental
is attendant upon all these advuutages, and the removal
to a more expensive locality ; but it is an increase which,
in tlie opinion oE the Council, the prosperity of the Society
will enable it to bear. I may justly congratulate the
Society upon the prospect before it, which, I feel sure,
will be the inauguration of an era of prosperity yet greater
tliuu before.
In other respects also I have to congratulate yoa upon
tho Bfttiefaotopy condition of year Society. An annually
increasing number of candidates present theiuBelvea for
our diploma for midwives. During tho past year the
number has been 170, of whom 148 pnsscd ; and the total
number on the register is now 761.
The Society haa thus boeu doing an important work in
this respect. But it haa always boeu in favour of legiala-
88
ANKVlir. AUDKKS8.
lion to establ!sli a register of miilwives, an<l Kui(al>te Ifsl
Biamiaationa throughout the country. In default of iegia-
lation, which lack of time for useful work in Parliament
has httlierto preventejj it lias been proposed of late to
estabiieh a volantary register for midwirea, in asBOciation
with a similar register for nurses. It is obTions that a
Tolnntary register might fail to n great extent tfl secure
tha benefitH which would follow from a compulsory owe,
since it would become futile if any large propoption of the
midwivcs did not choose to register theineelvea. More-
over, the midwivea themselveSj so far as tliey are repre-
Bonted by the Midwivea' Institute, the members of which
are holders of the diploma of our Society, prefer t« staud
by themselves, and decline to be aesocinted with mirsc«.
I ara glad to say, therefore, that this year there is again
a po»Bibility at auy rate of legislation, since a bill is to
bo introduced into Parliament by Mr. H. F. Pease, foUowinff
in the main the lines of the draft bill drawn up some years
ago by the Obstetrical Society, but giving to ihe new
County Councils the duty of appointing tho examining
bodies. The project lias received the approval uf the
General Mudical Council.
The number of volumes in the Library amounts now to
4138^ 134 having been added during the year, of which
4G were donations.
The eatiafactory financial position of the Society is shown
by the Treasurer's balance-sheet, which Las boon rend.
Tho surplus for the year is not, indeed, so great as on some
previous occasions, but even this is itself a testimony to
our sound position ; for the reason of it is that your
Council has thought tlie funds of the Society to bo in &o
favourable a condition that it could devote the main part
of tho fees paid by midwives for examination to givingan
honorarium to the examiners, who for many years had
performed their labours gratuitously, and whose work waa
becoming every year more arduous, owing to the multipli-
cation of candidates.
The total number of Fellows on December Slstwas 738.
AinnT4L ADDRB8B.
80
Thirty-eiglit new Fellows were elected during tlie year,
wliile 37 were lost hy resignation and crasnre, aud 9 by
dentb. In view of this ver)' slight decrease In our nuin-
l>er8, which has octniTed both in the last year nnd in the one
prccediugTi it mny not ^^ out o£ place to Guggeat to nil our
Fellows that ct large influx of new Fellows, such as has, I
belic'i'e, already commoncod to the Royal Medical and
Chirurpcal Society, would be no inappropriate accom-
pnniment to our removal into a moi-e favoured locality, and
the consecjueTit increase of our rental.
Charles Davidson, M.D. St. Andrews, F.B.C.S.Edln.,
L.K.Q.C.IM.. died on January li^th, at the age ot forty-
seven years. He was brought up, Rltliougli not bom, in
the Orkney Islnnds. He studied at Kdiuburg-h University,
and there tonk the degree of F.R.C.S.Edin. He then pro-
ceeded to Loiidun, where liis first appointuieitt was that of
Medical OfHcer to Bethnnl House Aeylum, After a time
his be«lth gave way; ho resigned that appointment, and
Bpont some time in travelling. Having regained his health,
he settled in Caasland Rond, Sontli Hackney, where ho
speut about twenty years in quiet, unostentatious hard
work. He was elected a Fellow of the Society in 18P3.
He was a member of the Council of the Metropolitan
Coonties Branch of the Hritish Medical Association, and
took an active interest in establishing the East Loudon
and South Essex division of the branch. He also held
the office of Surgeon to the 7th Middlesex Artillery
Volantecr Brigade.
Although not in rohust health for the last three years.
Dr. Davidson teemed fairly well and in good spirits, and
in the summer of 18^8 enjoyed a holiday in the Voagee.
Returning to Ijondon he resumed active work, but met
with a chill which cnt him oft after a few days* illnosg.
Dr. Davidson was a man of wide culture; his opinion
was worth having on the style of a hook, the ugefulneas
ot an instrnmont, or the choice of a picture. His profes-
sional attainments were groat. Perhaps he excelled most
OS a therapeutist; his knowledge of drnga was extensive
90
ANNrAL ADDBES3.
I
I
and precise. His code of profeBsional honoar was Iilgl),
aud he acted up to it. Hia keeu iutellect vras guided by
a. warcQ heart, and bngbteued by a maiiaer geuial u»
Hiimmer.
Hunter Jackaon Barron, M.D.,C.M.Ediu.,L.R.C.r.Lond.,
M.R.C.S.Eng.,, died on February 0th, at th& early age of
thirty-one. He was educated at the Cliarterhoiige School.
He very early pvinced hie love for natural history purauits,
and had made his choice of the profession of medicine.
He became a stmlent at St. Thomss'g Hospital, aud ma-
triculated at the Loudou University ; but having formed
the opinion that the oonree was too protracted, he went to
Edinburgh. He there took the decrees of M.B. and CM.
ill 18H3, and two years later thut of M.D. While at
Edinburgh, a patieiut in the hospital requiring it, be volao-
teered to supply thu necessapy blood for transfuaion.
Dr. Biirron paid especial attention to the study of
zoology, taking Sir Wyville Thomson's silver mednl for
pi-actioa] zoology at Edinburgh in 1879, and bt-ing an
occasional coatrihutor to the Britiah Museum of speciuiena
of British Mollusca, of which he had himself a. large ani
beautiful collection. He was also Pattiaon Medallist
in medicine at Edinburgh, and became a Fellow of ihe
Linnican Society, lie was elected a Fellow of this Society
in 188(i, having cBlabliahed himself in praclicoin Fiuchley
in IB85.
Dr. Barron was distinguished in athletics as well ns in
science. Ho had been a good swimmer from a very early
age, and waa well kuuwn in the Bwimining world ns a first-
rate amateur in the art. Ho took very great interest in chia
pursuit, and did all that hi* possibly could to encourage
it. He had been captain of the Otter Swimming Club,
aud also hon. Bccretary of the iSwimming Associution of
Groat Britaiu from 1H80 to 1883, and president in 188-i
and 1 885, doing much in both ihoac capacities iuv the cu-
conragomcnt of the art. Ou hi» rufiigning the position of
president ia 1980, ho was pi-cscnted by the delegatos o£
the Aasociation with a handsome testiiuouial, in npprocia-
AHNVAL ADDKB8S.
fll
la efforts to promote btiiI populnrisi' swimming'
geuerally. Portraits and momoirB o£ him as an amateur
svimioer appeared in the ' Bicycliog iind Athletic Journal '
of November, 1880, and tlie ' Sporting MiiTor ' o£ May,
1882, and lie had Eroia time to time contributed articlciS ou
hia favourito poatime to the ' Field ' and other papers. His
lore for swimming- as a sport was Bubordinalo, howoveTj to
his desire to eucouraf^e it as a health-giving, life-saving-
art, and he was never more pleased than when lecturing
to » school or institute on the Kuhject, or framing rules
for their guidance in forming clubs.
Dr. Barron suffered much mental anxiety in the year
188G, and in the autumn of thitt year the fir:^t symptoms
of diabctoa made their appearance. He never deceived
himself aa to the result, but preferred to work on until
the end, rather than give up. Ah a matter of fact he
visited patients two days before his death, and the tinnl
end wa3 due to his catching cold on his rounds.
Richard IJroughton Bothamley, M.R.C.S.Eng., L.S.A..,
died oD Mareh 14th, at the age of thirty-ei^ht. Ho was
born in Liucoluahiro, and received bis medical edueatiuu
at St. Thomas's Hospital. At Hir William Mac Coi-mac's
advice in lb7(> he went out to the hospital of the National
Society at Nish during the Basso-Turkish war, and did
nervioe also in the field in that war. His servicea as a
surgeon were highly appreciated, and he was decorated
by the Ottoman Government with the Order of the
Medjidi€.
Soon after hia return to England he engaged in prac-
tice at Bromley, Kent, where he was highly esteemed
as a practitioner by all ela.tscs, and heUl the ofhce^ of Dis-
trict Medical Officer, and elan that of Medical Otiicer of
Health. Ho died of typhoid fever, and umy bo said to
liave fallen a victim to his zeal for hi» profession, for he
worked almost to the last, aud kept his lied but tittle over
bat bis death was not notified otitil after tbc last anDual
meeting. He waa bom at the Bridge House, Cromford,
Derbrabire, being the third son of Abraham Wheatcroffc.
He WAS edncated at Unirersity College Hospital aiid
Sheffield Medical School. He was elected a Kellowof the
Society in 1870. For the Inst three years of his life be
practised 8t Brandsburton, in the East Kidiuguf Yorkshire,
He waa devoted to his patienie, by whom ho was much
beloved and renpected, especially by the poorer class.
He was also a .spurt^man, and was fond of fishing. He
died of rhenmatic fever after three weeks' illness.
George Charles Kemot, Ph.D.Giessen, L.D.S., R.C.S.,
L.8.A., died in June, 1888^ at the age of sisty-fonr, but
his death alao was not notified until the present year.
Ue practised in £lphinst«ne Road, Hastings, and waa
elected a Fellow of the Society in 18iJ5. He was the
nnthur of works, " Ou Afithma, luflneiita, and Bronchitis,"
published in 1852, and " The Qnestion of Vaccination, its
Advantages and Present Dangers," published in 1870.
Dr. OBCar Previt died at San liemo ou March 19th, at
the ago of ^fty-two. He was bom at Riga, where his
father practised iiti a medical man. He was edncated at
a school at Birkenruli, near Wenden. In the year 1857
ho proceeded to Dorpat University, He there studied
medicine from 1857 to 1861, and again, after a short in>
terval, from 18G3 to 1861, taking his Doctor's degi-eo in
1861. After thiii ho %isited the Universities of Berlin,
Vienna, Wurzburg, ond Paris. On his return from abroad
he settled in practice at St. Petersburg, where ho held
the office of Director (" Ordiuator ") of an ophthtilmic
hospital from Soptembei", 1865, to March, 1867. Ho then
removod to Jaroslaw, being nppoinled Director of the
State Hospital in that town. Next he was appointed chief
physiciao to the Gyuaicological Department of the Fin-
delhans Lying-in HoHpiLal at Moscow, nnd passed the last
years of bis life in that city, where ho had a large obstet-
rical and gyuGDoological practice. Ue waa elected a Corro-
apottding- Fellow of our Society in 1876.
I
XmSVi-L AOUKKSS.
Johr. Rutherford KipkpaLriclt, M.D.Dubl., F.K.Q.C.P.
Ircl&utl, died ou April I6th, at the age of Mty-seveu.
Ho became a Licentiate of the Royal College of Sur^ous
of Irelaad iu 1855, and two years aubsetiueutly obtained
the Folluwr'ship of that Cullogei Lj* examination, but in
1879 resigned it on being elected a Fellow of t]i« Itoyal
College of Pbyincians of Ireland, of which be had pi-e*
vioualj been a Licentiate. Ho was also an M.B. of the
UEiveraity of Dublin,, having been educated at Trinity
Collo^, Dabhn, nnd took the M,D. degree in 18S:J. He
was appointed AsRislunt to the late Dr. McClintockj the
then Master of tho Rotunda Hospital, about the year 1858j
and served in that capacity for the usual term of three
years. In 1882 ho was elected King's Professor of Mid-
wifery by the Fellows of the Royal College of Physicians,
and lectnred in the school of the University of Dublin.
His seven years' term of office would have expired in July,
and very recently he was re-elected for a ftirtlier term
of sewn yeai-s. He was also Obstetric Physician to
Sir Patrick Dun's Hospital, and Physician to the Maternity
Charity iu connection with it. U« waa a Member of the
Boyal Society of Dublin, and a Fellow of the Academy of
Medicine in Ireland, and hud been Kxatuiner in Midwifery
for the College of Surgeons and the Queen's University of
Irelaud. He was elected a Fellow o! this Society in 18(32.
Dr. KIrkpalrick'a life was coinpnrutivfly uneventful.
He did not contribute very largely to lilerature, but was
the author of various papers on obstetrical subjects, among
which may be mentioned one " On the Prevention of
Accidents arisiag from the Use of Pessariea," and onu un
the " MauikgemeiLt of the PerinEeum during Delivery."
Ho soon acquired a very large obstetric practice, which
ho retained np to tho date of his lost illness. Uia kind
and gentle maimora endeai-cd him to his patients. He
was beloved and esteemed by all who knew him, and
never bad nn enemy. Hix health had been for some timo
declining. The aclaal cause of death was not ascertained,
but he became very aneemic, and appeared to die of
94
AKMFAI. ADD BBSS.
anEemia. His t-emams were interred in Mount Jeromo
OomatSFyj and the funeral was large and represeutntive.
Lawrenco Treat Cnmberbatcli, M.D. St. Andrews,
M.H.C.P.Loiid., M.R.C.S.Eug., died August IStli, at the
age i)E sixty-five. He wns born at Barbadoes, where his
father owned an eetatc. Barlj iiiclination led him to the
study of medicine, and at the ago of sixteen he entered
as a student at Trinity Coltege, Dublin, where he took the
degree of B.A. in 184(i. After tliis he studied for soma
time in Paris, and thou, in 184y, took the Membership of
the Royal College of Surgeons of England, not bcjnff nblo
to afford the time uecosaary to graduate in medicine. Ha
nextbccume assistaDt to a practitioner at Chipping Norton,
who Lad an extensive practice, and held several appoint-
ments, iiiduding a large; Uuion. By laborious work iu
this position be gained extensive experience both in
obstetrics and in general medicine and surgery.
His first commencomout of practice iu Loudon was
decided by an accident. A nomination for a coramiasion
IIS assistant-Burgeoa in the array had been obtained for
him ; be had resigned Lie appoiutineut, and had come np
to London to present himself nt the War Offioe. It was
then found that Lis diploma of M.B.C.S.Kng. could not
for the moment bo produced, hia ancle to whose care he
had entrusted it being out of town, and thus his com-
mission was lost. In this dilemma he decided to com-
mence practice near Lowndes Square ; and, having influ-
ential relations and frieuds at the West End, he soon
began to attain success.
Eventually he decided to give np general practice, and
limit himself to obstetric and medical work as a physiuiau.
AccDi-diugly, in IS&O be took the degree of M.D. at St.
Andrews, and the Membership of the Itoyal College of
Physicians of London, His inclination for obstetric prac-
tice wfts mnob encouraged by three inHuential friends, all
having largo and fashionable midwifery prjvctices, the bite
Sip Charles Lococt, Br. Cape, and Dr. Gream. AH these
availed themselves frequently of Lis obstetric skill ; and
I
AKHDAL ADD BESS.
95
thus it happened that beFore long Dr. CumWrbatch him-
self was in the full tide of a large obstetric practice among
the upper classes at the West End.
His great success was the more remarkable from the
iact that the only public appuinttuent he ever hohl wns
that of phynician to the Economic Lite Insurance Office,
which he retained up to the time of liig death. It was
dne to his own talent, iiidustiy, and professional skill.
A writer in the ' Laucel ' nays, " Only those who have
hod the advantage oF meeting him in consultation can
know bow yahmblc was his opinion j how thoroughly
honext aad straightforward ho was, and of what comfort
and support in difiicnlt and complicated cases. To his
patients he endeared himeelf by his sympathy, aa well as
by his HuccesH in treating thi'm. In addition to being n
good classical scholar he was well read in subjects apart
from his profession, and was always thoroughly versed in
the topics of the day. As a host or at a dinner party he
was delightful, and those wltu have met him know what
BD aM^nisitinn he wa^i. Full of amusing anecdote and
sparkling humour." Dr. Cuinberbatch was elected a
Fellow of our Society in 18C2, was a Member of Council
from laetf to 1870, and was Vice-President in 1878.
Dr. Curobcrbatch had had a warning about seven years
before, discopcnng that his pulae had suddenly fallou to
■bout 4rO in the uiuute. Acting on tlii> advice of medical
friends whom he consulted, he then gave up his midwifery
prtctice, and limited himself to consulting and medical
work. Nevertheless he remained fully occupied with the
work which now fell to his Bhare as a general physician.
After a busy sessou he left Loudon on the uigbl uf
AagoiitlGth to join his cousiu'a yucht in 8cothind. With
tlte exception of some fatigue ho appeared well on his
urrival. On Sunday, l8th, at breakfast, he appeared in
his usual spirits. Soon afterwards he was seized with
sstero pain, which at first he attributed to indigestion, but
which was evidently angina pectoris. He remarked that
he had had a flight attack of the same kind the previous
fi6
AKNDAL ADSICKSS.
Sunday. The p&in iucreaaed, and in less tliaa half ao
hour from the moiaent of seizure he <lie<J.
Francis Jninee Bailey, L.R.C.P.Lond., M.B.C.S.Eug.,
iiud L.S.A., died October ;^Oth, at the age of fifty-six.
He was the sou of Mr. J. Bailey, sui-geoa of Biackburu.
He ^ttidiod luedieine at Chariug Cross Hot^pital, took thd
quallEcations of M.E.C.S.lilag. and L.S.A. iu 185(5, and
in iy7! becume li Licentiate of the Hoyal College of Phy-
Dicians of London. He began practice in Livei-pool as
partner to Dr. Nottage, and took the practice on the re-
tirement of the latter.
He acquired a high-class practice, was well known in
professional and literary circles, and took an actlvo part
in the wort of several learned societies. He was Vico-
Prtsidcut o£ the LaucAshire and Cheshire Historic Society
for upwards of eleven years, and also President of the
Liverpool Pliiloniatliic Society. At the time of hia death
he was Chairman of the Dental Hospital, and Vice-President
ot" the Liverpool Medical Institution. He was also a pit)-
miaent mason, being P.M. of the Croxteth United Service
Lodge. He was much interested in the education of tho
deaf and dumb, having served for seventeen years as
Honorary Surgeon to tho Deaf and Dumb School, and
also to the Adult Deaf and Dumb Society. At the last
uoctiog of the Medical Institution before his death he
spoko against tho introduction of the pure oral method of
traiuiug the deaf. He held tho rank of Surgeou-Mujor
(Honorary Lieutenant- Colonel) in the volunteers, having
served in bis corps since IQGZj and baTing accompanied
it to Aldershot in 1886.
Dr. Bailey had not been in good health for some time,
but continued his ordinary work till the day before his
death. Ho had an apoplectic seizure of a very severe
character, never rallied, and died in a fow hoarn. His
funeral was attended by a nuacrouE citcle of frionds from
the medical profession, tho Volunteer force, and Masonic
body, ns well as from tho learned uocietiea to which he
belonged.
ItfiSS.
«7
Dr. Bailey irafl elected a Fellow of our Society in 1880,
and contri1>ut6d to the journats some papiers od o1>atetnc
subjects.
The scienlilio work ot our Society during the year, as
contained in tho volume of *" Transactions ' juKt ready,
will be found, 1 Taelieve, not to fall short of that of previous
years. The spec! mens shown hare been of great patbologncal
interest, bcariu^ mainly upon diseaees of women, but in
some coses also upou points conuecti'd with obstetrics.
No lees than four specimens bayi; been shown of aaeu-
coplialic fcetus, and we haii'e liad besides "Notes ou a
Caae of Anencephalic Monster" in the form of a paper by
Dr. H. C. Hodges, One of these moustei-ii shown by Mr.
Alban Doran had the pecnliaritj that there was a mass of
rudiineatary brain-snbst&nce covered with pia niaterj which
Mr. Doran considered to snpport the theory that the anence-
phalic monster results from rupture of a hydrocephalic
head at the third or fourth week of pregnancy. In Mr.
Hodges' caso there wns a soft pedunculated brain-sac,
lying behind the frontal bone, which was ruptured m do-
Uvery.
We hare bad also an unusual number of specimens
bearing on the pathology of pelvic hietnatocele. While
some of the t^ourceaof blcxid which are commonly assumed
to be possible in this affection, such as regurgitation from
the Qterus of nion»;trual blood, or rupture of varicose veins
intbe broad ligament, rest rather upou n ^rt'ori assuiuptiou
than upon demonstration, it has been abundantly proved
that one possible cause is bleeding from a diseased Fullo-
pian tube, whose ostium remibiuH patulous. Two spoci-
mens where this condition had given rise to hsematocele
were shown during the year, one by Dr, Playfair, one by
Dr. CuUiugworth. Another aouiewhut different source of
liajmorrbage woe shown in another specimen, presented
also by Dr, CulUngworth, in which a hn)matos)ilpiux had
roeulLed from rupture of a vurieose vein in the lining of
the Fallopian tube. How small may be the source of a
fata! intra-pelvio hstnorrhage was strikingly illustrated by
TOL. XXXU. 7
08
ANN DAL AODBKSS,
a specimen shown by Mr. Knowsley Thornton, in wHch an
extm-Qterine &ao, not larger than a hnzel-nut, and Bitiiatod
closa to the angle of the uterus, bud ruptured, Mr.
Thornton deduced from the specimen the important ang-
gestiou that in such a. c&se, the patient being greatly
coUapa«d, it would be better not to remove the tabe, but
Bimply arrest the bleediug by a double ligature. A still
more rare form of fatal iatra-pelTic haemorrliage was illus-
tratod by a specimea of pelvic hiema,toma after delivery,
presented by Dr. Boxall.
The rarer forms of tumonr in or near the ovaries have
been illustrated by several specimens. Two were o£ 6bro-
myxosarcoma o£ the ovary, shown, one by Dr. Handfield-
Jonesj one by Mr. Meredith. Dr. W. Duncan showed a
nayoma of the broad ligament ; while tumours of the ovary,
partly adenomatous, partly dermoid, were shown by Mr.
Bland Sutton and Dr. Carter.
Many apecimens have been sliown throwing further
light upon inflammatory disoaeos of the uterine appendages.
Distended tubes have been shown by Dr. W. Duncan, Dr,
J. Phillips, and Dr. Culliugworth. But the specimett
■hown by Dr. Playfnir was of special practical significance,
where death hnd followed the skilful aud successful re-
moval of an intpa-utorine polypus, and was found to be due
to a pyosalpinx which had escaped detection. Still mora
instructive, from the pathological point of view, were the
specimenB associated with the paper on the " Closure of
the Ostium in Inflammation and Allied Diseases of the
Fallopian Tube," by Mr. Albau Dorau, who based upon
theae specimens a distinction between salpingitlc cloeure
and perimetritic closure of the ostium.
A curious point bearing upon the microscopic diagnoflial
of the nature of membranes expelled from the utems wu
raised by a specimen of dysmenorrKoeal membrane ex-
hibited by Mr. Alban Dorau. The patient had had her
ovaries and tubes removed n year before, and sections of
the membrane showed large cells resembling decidual
celtfl,
ABVC^AI. ADDRESS.
99
special interest attacL^e to Dr. Miinchmeyer's apparatus
for the trausfusiou into tha cellalar tiasue of a sfreriliaed
Kaline eolutiun in cnees of heQmorrbii.ge, which was abown
by Dr. KTattliews Duncan. The interest belongs not
merely to the actual instrument, but to the faot that any.
one can easily improvise an apparatus for carrying out
this method, which ha» been practised to a considerable
extent in Germany and elsewhere, and which la alleged to
give rctiult«i quite us great as tlioae of an intra-veDoua in-
joctiOQ of saline fiuid. All that is wanted is an aspirator
needle, Bterilised by the flame of a spirit lamp, a piece of
elastic tubing, and a large funueE. Ad antieeptie Bolution
is first passed through the apparatas, and then the tialine
aolation is injected into the celtulur tiHsiie by the force of
gtvmiy. It is diffused in that tiesue, if necessary, by
maMage ; and the flow can be accelerated by running the
oiled finger and thumb down the outside of the tube.
Yet it may be well to remember the investigatiuu made
some years ago by Prof. Schafer for titis Society by numo-
roos experiments on nnimnli?. Prof. Scbiifcr coucludod
from those exporirocnt* that the cause of death is generally
lack of snfficient blood-corpuscles to carry on respiration,
that intra-venous injectiouK of Baliue fluid are therefore of
no avail, and that the only means of saving life is direct
tranafusion of blood from an animal of the same species.
The papers of the year have been somewbat above the
avemgc in number, aod midwifery hiis not had quite so
much prcpondemnce as usual over the diseaBes of women.
Of twcnty-ono papers, eleven were on obstetric subjects,
nine on disenecs of women, and one, by Dr. Hodges, on
biematemesis in a new-born infant.
Dr. J. Phillips's paper on "Acnte Non-septic Pnlmonary
Disorders ns Complications of the Puerperium " mised
various questions of great interest. The author adduced
evidence to ^how the existence of a disea8e distinguishable
by its fligns fi-om ordinary pneumonia, and having special
relations to phlegmasia dolens, from the fact that it oc-
cmred about the same date in tho pucrperiam, and that
100
ASNOJLL ADDRESS.
pTilegmasm dolens was in several Cfises a complipation.
ile considered that it arose from genenil ihrombosis of tha
minute pulmonary venules, produced hj the same condi-
tion of tLoWood wliicli is productive of phlegmasia doleuii.
Some of the apeukers were doubtful of the uou-utptio
character of the oasos, and porliapa tho difference may
really lie in o«r dofinition of septiciemia. For the- saiiie
doubt occurs about phlegmasia dulsuB itself. Some regard
it as septic, while others refnuo it that title, on. account of
ita late occnrrenoe and its favourable prognosis. If this
Bpecial pneumonia depends upon a form of microbe differ-
eufc from the ordinary microbe of pneuraonin, and from
those of any named aymotic diseaseSj and if the puerperal
state 16 a necessary predisposing cause, ought wo or ought
mre nut to refuse to include it in aepticoimia, because the
microbe probably doos not gain accosa through the genital
canal? I think wo can scarcely do 80 logically if we give the
word septicajmia its widest uieaning. For 1 am not my-
self prepared to agree with one of tha Bpeaker.-^ thdt ecpti-
ca3mia is a disease with a course and phonomeua &b defi-
nite as tliose of any other infectious disorder. Rather, it
varies in degree froui an evanescent febrile diiitiirbanco
to the most virulent and fatal disease ; aud^ as to its pheno-
mena, there are the greatest varieties as to the presence
or absence of peritonitis, parametritis, phlebitis, lympban*
^tis, and other local lesions. And, though we do not yet
know enough of its bacteriology to esplaiu it, tho microbes
which liavo been found are not of ono apocios, but of
several.
Dr. Handfield-Jonoa' paper on " Chorea in Pregnancy"
contained the reports of two cases marked by the associa-
tion of chorea with mauiaeal disturbance. The author
regarded chorea in pregnancy as an example of disordered
function ; other speakers considered that the term func-
tional disorder is in thifi case only an expression of onr
ignorance. Neither this nor any other paper has yet fully
cleared up the mystery of chorea, especially as regards
tlie relation between psycKic causes and organic lesioDs.
AmtFAL ADDBIBS.
101
In ono ease chorea reanlted from fright at theClerkcnwol!
esploBion. Tho patient died, Btid at the nocropsy wore
seen those vegetations on the cnrdmc vulvos wliiuh are so
generally found, even when there baa been no bruit dur-
ing life. How can a fright produce vegetations on tbe
valves? or wK&t intermediate Uuka of causation can be
imagined between theio, eapeciaily when wo remember
that, according to ojie theory, tlie vegetations are the
primary canse of the chorea ? Similar considerations
apply to the relation of chorea to pregnaacy.
In his paper on " Ctesarean Section for ContraoteJ
Pelvis," Dr. Cliampneys gave a, very full report of a suc-
cessful oporatioQ carried out according to Stinger's method.
In this operation tlie novelty was introduced of steriHaing
the patient, not by removing the ovaries, hut by tying tho
tubes with kangaroo tendon.
Dr. Herman contributed three valuable papers, the re-
snlt of extensive clinical observations : " A Contribution to
the Anatomy of tho Pelvic Floor," " The Changes in the
Pelvic Floor which accompany Slighter Degrees of Pro-
lapse," and u paper on " Five Cases o£ Puerperal Kclanip-
atfti" In tho last it was shown that cases of eclampeia
differ materially from each other; but the most constant
feature appeared to bo the diminution of the excretion of
nreiL, though not invariably of the qiiaulity of urine, dur-
ing the period of the fits.
Two cases of reposition of an inverted uterus were re-
oorded, one by Dr. Braxton Hicks, on© by Dr. Newman.
Other papers on obstetric subjects were on'" Diagnosisof
Placenta Prifvia by Palpatiou," by Dr. Spencer ; " Lacera-
tion of Vagina in Labour," by Dr. Matthews Duncan ;
and " Shall Pregnancy be terminated prematurely in Cases
of Phthisis? " by Dr. W. Duncan. On gyniecological sub-
jects we have bad papers on " Chlorosis and Menstrua-
tion," by Dr. Stephynson ; " Large Chylous Cyst of the
Mesentery," by Dr. Itasch ; "Vesico-utero-vaginalFlBtula,"
by Dr. Cullingworth ; and " Lnpiis of the Vnlvn," by Dr.
liBwers.
102
AHHOAL ADDEESB.
TLere are other subjects attracting special interest at
the present tirae, eapeciallj ou the Continent, on which
we have not had papers during the past year, but may
hope for further commnni cation 3 in future. One of these
is the operative treatment of ciineer ot the cei'vix uteri.
It is generally assucuod tliat the spread of the disease is
more outward than upward; and, in -view of this fact,
when the suhject was last discnssed in our Society the
general opinion was in faTour of the supra-raginal ampu-
tation rather tha,n total extirpation of the uterus through
the vagina. Bnb thia decision must be cither confirmed
or modified in view of more recent experieoce. It is
known that, in some exceptional casem, extension upward
to the body of the uterua is oven more rapid than exton-
aion outwards, and it would be of importance to hnowthe
relativo frequency of tliese. In Germany opinion inclines
rather toward total extirpation ; and Dresden, which baa
obtained cuch wonderful results in Ciesarean section, claims
a mortality of only '» per cent, after totivl vaginal extir-
pation, and a percentage of more than 25 free from re-
cnrrence after two years. On the other hand, it ia con-
tended by BOme that recurrence ia bo general after supra-
Taginal amputation, and the pains of deep-seated recur-
rence so much greater than that of the untreated disease,
that it is better to abstain from all attempts at extirpation.
It would be of importance also to confirm or correct the
observations of some German authorities who find the
endometrium of the fundus, even when not reached by con-
tinuous extension from the cervix, yet almost invariably
diseased, either by actual sarcoma or by n proliferating
endometritis suggestive of commencing inaligimncy.
Another eubject is the treatment of complete rupture
of the aterus in labour. This was indeed raised during
the past year by a specimen shown by Dr. Horrocks, and
the opinion was oxpreaaed that abdominal section ought
always to be performed, and the uterus removed by Porro'e 1
method, if the rent could not be Bewn up. But removal
of thent«rus muBt add to the great shock already exititing;
VOTSa O? THASKB.
108
and, tlie rent being in the lower distensible segment, and
often spreading into tiie broad ligament, it cau rarely be
possible completely to remove tlie torn portion, In con-
nection wicli tliis siiTjject tlie auccefisful boldness of Leopold,
who left iodoform gauze for a time in the peritoneal cayity,
to secure apposition through pressure of the peritoneal
edges which could not be sewn, is deserving of attention.
Gentlemen, I thank }'0a heartily for the courtesy which
you have shown me since I have occupied this chair, and
I look forward with a confident hope to a year of yet more
valuable work in our new meeting-room.
Dr. GiiBTia, in proposing a resolution of thanks to the
President for his address, said it was worthy alike of his
genius, hia reputation, and his position as FreHident of so
important a Society ; and, beyond the thanks that were due
for the address, the Society was alao deeply indebted to the
President for the care which ho had taken of its intereets
in the negotiations with the Royal Medical Bud Chirurgioal
Society, and for tho very H-ble manner in which he had
brought them to a pleasant and satisfactory conclusion.
It was then moved by Dr. Qkevis, seconded by Dr. John
Williams, and carried with enthusiasm — "That the best
thanks of the Society bo given to Dr. Galabin for his
interesting address, and that he be a&ked to allow it to
be printed in the next volume of the ' Trauaactions.' "
A vote of thanks to the retiring Honorary Secretary
(Dr. Percy Boultou) and the retiring Honorary Librarian
(Dr. HorrocJcs) was moved by Dr. Heeman, seconded by
Dr. AcBT Lawkksce, and carried unanimouely. In speak-
ing on this vote Dr. Williams referred to the heavy
extra, duties which had been undertaken by Dr. Boulton
in consequence of the negotiations with the Royal Medical
and Ghirurgical Suciety^aud most ably coudocted by that
gentleman.
A vote of thanks to the retiring Vice-Presidents, Dr.
Brodie, Dr. Cleveland, Dr. George lioper, and Dr. William
Stophonsou, and to the other retiring Members o£ Council,
104
VOTBB OF THiNKS.
Br. W. Duncan, Pr. Handfi old- Jones, Dr. Hurry, Dr.
Lewors, Mr, Lowe, and Dr. John Phillips, was luoved by Dr.
Lkith Napibr. He said that however esoelleut the Pre-
sident for tbQ time might be, it iriis essential that lie should
be wisely aud efficiently supported by his officers and
ooimcillors. The work o( the Vice-Presidents might not
l)e onerous, but their positions were honourahle. Witt
regard to the four retiring Vice-PrLieidonte, Dr. Napier
felt auro that he expreseed the convictions oE all present
in saying- that four more thoroughly worthy and highly
apprcfiiited gentlemen had never served the Society. One
oi those gentlemen h&A now ceased practising Ins profes-
sion, after hnving well earned his honorable leisure. Of
him Dr. Napier might stiy that no more entliUHinstic or
devoted Pellow ever helonged to the tSociety. For years,
in the midst of a busy life, he had found it a haven of rest,
and lie rightly valued highly the horiouiuble place which
he oocapied. The other three gentlemen were still with
thorn professionally, aod Dr. Napier trnsted to seeing thoin
OOOUpy a yet hlglicr puaitiuu in the Suciety than that they
had just quitted. The duties of the Council had, daring the
past ycar^ been peculiarly arduous and trying. It argued
well for tho ftitnre o£ the Society that under «11 circuui-
Etanees the most perfect harmony always existed between
the Council and the general body of Fellows, While the
Council lost, the Library gained, the valued aervlceB of Dr.
Wm. Dnncan. Dr. Napier concluded by expressing in warm
tertns tlie feeling of the Society thai the resolution, al-
though essentially and necesearily formal, waa amply
merited by the gentlemen to whom he had referred.
Dr. KoQTH had much pleasure in seconding the motion
of Dr. Napier. Ho would not, however, make an eloc|uent
onttioa like that member, but he would say that every one
of these gentlemen, whether Vice-Presidents or otherwise
Members of the Council, were men well known in their
profession. He therefore felt they had worthily merited
a vote of thanks for excellout work done iti the Society.
The votQ of thaukti was then carried unanimously.
SPECIAL GENERAL MEETING.
Maech 5th, 1890,
A. L. Gaubin, M.D., President, in tho Ohair.
Preaenfc— 40 Pellowa and I Visitor.
Books were presented by Mr. AJban Doran, Dr.
MatthewB Duncan, Dp. Goodell, the Boyal Medica.1 and
Chimrgical Society, tlio Ainorican Oyii ecological Society,
the St. Bartholomew's HoBpital Staff, and the "Westminster
Hospital Staff.
J. Fredk. W. Silk, M.D.Lond. ; Charles Herbert Tbomp.
son, B.A., M.D.Dubl. ; and C. Percival White, M.lt.C.S.,
■were admitted FoIIowb of the Society.
Harry St. Clair Gray, M.D. (Glaagow) was declared
admitted.
The following gentlemen wore elected Fellows of the
Society : — William John Gow, M.D.Lond. j and A. Aylmer
Orr, M.A., M.B.Oion.
The following gentlemen were proposed for election : —
Aogustns W. Addinaell, M.B., C.M.Etlin. ; George Edward
Ansou,M.A., M.D.Oantab. ; George Black, M.B., B.S.Lond.;
Albert Ebrinann, L.B.C.P.LoDd.(Soutliara)i Charles Arthur
Morria, M.A., M.B., B.O.Cantab., F.B.C.S.; Frank Fredk.
Scfaacbt, B.A., M.B.Cantab.; Hugh Smith, M.D.Lond. ; and
Ernest Allred Snape, L.B.C.I'.Loud.
TOL. xxiu. 8
108
ALTBEATION Of LAWS.
The following additioniLl Boction to Chapter XIX of the
Laws was put to the meetiug by the President from the
Chair, and carried uaanimoosly :
" Chapter XIX. — O? the Socibti's Peopertt. — Seo. 2.
—In order that the Society may in all respects conform
with the provisions of the Statute 6 and 7 Vie-, chap. 36j
seo. 1, the Funds of tho Society shall at all times ba de-
voted to the purposes for which it was instituted, and no
Dividend, Gift, Division, or Bonus in Money, shall at any
time be mode unto or between any of the Fellows."
It was then put by the Presideot and carried rtem. con.
that Chapter yill. Sec. 1, of the Laws be altered bo aa to
read as foUowe :
" Chaptkb Vin. — Of thk: Tbustbbs. — 1. There shall be
three Trustees of the Society, in whom all the Stocks,
Funds, and SecuritieB of the Society for the time being,
Bnd also any Freehold, Copyhold, or Leasehold property
of the Society shall be T«Hti-d upon trust, from time to time,
to pa.y the Dividends, Interest, Rents, and Income thereof
to the Treaauror of the Society for tho time being, and to
apply and dispose of attch Stocks, Funds, Securitios, Pro-
perty, and Income for the benefit of the Society in such
manner as shall be directed by the Council, subject to tho
control of General Meetings of the Society ; and upon going
out of office, the Trus^tees shall execute all necessary deeds
and instrunjenta as the Conncil shall require, for vesting
all their iutereab in the funds and property of the Society
in their eucceaaors in the Trust."
The Meeting then confirmed the action of the Conncil
with regard to the terms of the Lease.
107
Beport on Dr. Robmson's Specimen of Placenta PrsBvia
(p. 67).
The ntems has been opened along its front wall, to
which the placenta was attached. The placenta is com-
pletely detached, bat it is impossible to say how much of
this detachment is due to its dissection. The insertion of
the placenta was probably marginal, but the condition of
the specimen precludes any detailed report.
W. S. Platfaib.
F. H. Chaufnxtb.
C. J. GnLUNQWOBTH.
108
THB BrpBcr or vni bimdkb
THE CHANGE IN SIZE OF THE CHEST AND
ABDOMEN DURING THE LTING-IN PERIOD,
AND THE EFFECT OF TEE BINDER UPON
THEM.
By G. Eehbst Hebman, M.B.Lond., F.R.C.P.,
OaeTZCUIC TSTSICIAM TO tB> UfSVQV HOaPITUi,
(Beceived November Ttti, 1669.)
{Ahsiraet.)
Thb author says tbu.t tbore axe tliree reasons commonly gireo,
by medical men or bj the public, for the uee of the " binder "
duiiDgtheIying-iiip«riod, (1) That it gives eomfort. (2) That
it couuLeracts the iujurious effect of tbo euddeu lowering of the
intra-tibdoniina-l pressure consequent on the eyacuation of tlia
uterus. The author points out that It is not usually applied
till after the time at -which ihn lowering of preaaure takus place.
(3) That it keeps the waist measurement small, and so preserrea
the " figure " of the patient. To judge of this it is necussarj
to liiiow what changes normiilly take place iu the tyiug-in
poriod. He adduues meaauretnunta madeat the Ocaeral Lying-
in Hospital, which show that during the first ten djijs of the
Ijring'in the circumfcrenee of the lower )>art of the ohest (at
the level of the ensiform cartilage, and also midway between
this point and the umbilicus) diminish b^* rather more than an
inch. This diminution ia priicticallj the same in primipano and
tuultiparee, and is not modified by age. Th« effect of tbo
"binder" is ascertained by comparing different (jlassea of
p&tieuts: (1) with a binder as ordinarily applied ; (2) without
a binder; (3) with a binder to the continued ti^'Ltnesa of which
8p«cia) attention w&b given. It w-ao found that the dimiuutiou
in size of the lower part of the cheat ia practically the saow in
each class. The author therefore concludes that the ordinary
binder has no effect uu the waist measurement of the jMtieut ;
DUKlira TEE LTDfO-IH PEBtOD.
100
althoagh ho does not doubt that by the use of an unyielding
bandage, tigibt«iied by stripe, defonuity of the cheat mig^bt be
produced and mainta,med. The sole utility of the ordiuarr
bmder is aa a m«aa8 of comfurt to the patient.
It is usual aft^r delivery to pat a " biader " round the
ftbdomen. There are several reaaons commonly accepted
for this practice. One that may be given is that the
binder afforda the patient a comfortable sense of warmth
and support. This reason is good, but does not admit of
discussionj because the sole and unanswerable evidence of
this effect is the patient's ipse dixit.
Another reason is that, unless sonio compression be ap-
plied, the sudden lowering of the intra-abdominal pressure
which results from the emptying of the uterus may pro-
dace fiome injurious effect. 1 will not considorT?hat these
effects may be^ or what evidence there is of the connec-
tion of such effects with fheir supposed cause, but will
only point oat that as tho binder is not usually applied
uuttl an hour or so after the sudden diminution of pres-
sure has taken place, it comes too late to prevent these
effects — at least such effects as depend upon the sudden-
ness of the lowering of pressure,
A third reason, which I think is the chief one in the
mind of tLe public, and often given by medical men to
their patients, is that by firm binding-up after delivery,
the patient's " figare " is preserved. Converselyj we
Bomctimcs hear the blame for a patieut's portliness being
put upon the medical man's want of attention to tht; binder.
The alterations in the figure which follow repeated
child-bearing, are difficult to distinguish from those which
are merely the result of age : and some of them, each as
the deposition of fat, and increased curvabate of (he spice,
cannot be iu the least affected by the biader. The change
irbioh the binder is presumed to modify, is the enlarge-
ment of the chest and abdomen. That the girth of the
waiat can be reduced by comprespion, is shown clearly
enough by post-mortem exatninatioos of patients accus>
no
THR BPFBCT OF TBB BI¥DER
tomed to lace tightly. I therefore aee little reaaon to doubt
that the waist can be redaced during the Ijing-in period
as well as at other times. But it does not follow that any
permanent or considerable alteration can be produced by
the ordinary binder applied during the week or fortnight
following delivery.
Tiii& communication is based npon measurements made
to ascertain what change takes place in the base. of the
chest and the abdomen during the lying-in period, and
what is the effect of the ordinary binder on these oh&ngea-
The measurements have been made for me by Dr. C. Owen
Fowler and Mr. G. A. Pratt, house physicians to the
General Lying'In Hospital; and I am additionally indebted
to Mr. Pratt for help in calculating the averages which
are snbinitted.
The only observations of a similar kind are those of
Kehrer.*
He finds the average circumference of the base of the
chest in twenty virgins, aged from 20 to 30, to be 72'8
cm. ; in twenty-one primigravidra, 81*7 cm. ; in twenty-one
meaeured on the third day of lying-in, 73'9 cm. In four-
teen seonndi gravid aa the average circumference was 80*9
cm. ; on the third day of lying-in, 734 cm. In ten multi*
gravidee the average circumference was 81 '4 cm. ; on the
third day of lying-in, 75-7 cm. The total of the whole gives
the average of forty-five gravidic 81"3 cm.; on the third
day after delivery, 74*1 cm.
He foand the greatest circamference of the abdomen in
113 first pregnancies to be 96'6 cm.; immediately after
delivery, 86-6 cm. ; in the lying-in period {I suppose on
the third day, bat this is not expressly stated), 82-C cm.
In seventy-five secundigravidae, the greatest circumference
was 99"3 cm; immediately after delivery, 89*1 cm.; in
lying-in period, 85'6 cm. In fifty multigTuvidee the greatest
circumference was 1005 cm. ; immediately after delivery,
90 cm. ; in the lying-in period, 85*1 cm. The average of
■ ' Bdtrige sar klia. uud axp. Qeh. iind fiju.' 8t« Band, 8lc Hoti, &. 307,
18B4.
DdKINO TBB LTINO-IM PERIOD.
HI
llie whole, in pregnancy was 58'2 cm.; immediately after
delivery, b8 ciu,; Inttr on, 84*1 cm. The average girth
Bt the nmbilicuB he found in twenty-two virgina to be
78"5 cm.; in 113 primigravidro, QB'I cm.; immediate]y
after delivery, 84'2 cm.; in the lying-in period, 80"5 cm.
In seventy-five secuodigravidte it waa 97*5 cm. ; imme-
diately after delivery, 85'9cm. ; in lying-in period, 83-1 cm.
In fifty multigravidffl it was 98'2 cm.; immediately after
delivery, 872 cm.; in lying-in period, 83'2 cm. The
average of the whole, in pregnancy waa 96*5 cm. ; imme-
diately after delivery, 86'S em.; in lying-in period,
81-9 cm.
In eighteen priraigravidfe measured by Mr. Pratt, the
citOumfereuce at the level of the ensiform cartilage aver-
aged 30-9 in., OT 78*5 cm. (Kebrer, base of chest 81*7
cm.). In eleven maltigravidsa, 29'9 in., or 76 cm. {Kehrer,
base of chest 81-1 cm.), it averaged midway between
ensiform cartilage and umbiHcus, 32'8 cm.; in eighteen
primigravidiB, 32*8 in., or 83'4 cm, ; in eleven multi-
gravidw, 32*5 in., or 82-5 cm. Kehrer gives no measare-
ments at this point. At ambilicas, in eighteen primi-
gravidee, the average was 35*2 in., or 89-b cm. (Kohrer
9b'l cm.). In eleven multigravidie the average waa 33*7
in., or 85*5 cm. (Kohror 97*7).
In fifty-eight primiparro the average circnwiferenco at
the ensiform cartilage on the day following delivery was
29*2 in., or 74-2 era. (Kehrer, third day 73-D cm.).
In seveoty multiparte the average circa mference at the
ensiform cartilage was 2927 in., or 74"4 cm. (Kehrer, third
day, 74-3).
In fifty-eightprimipane the average ctrcumferenoe mid-
way between the ensiform cartilage and the umbilicus on
the day following delivery was 29'3 in., or 74-4i cm. In
8cventy-ono niultiparffi the average was 30'6 in., or 77*8 cm.
In fifty-seven primipune the average circumference at
the umbilicus on the day following deliver}- was 30*04 in.,
or 77"8 era. [Kehrer 84-2 cm.). In sixty-seven maltiparas
it was 81-10 in., or 7J»-2 cm. (Kehrer 86-4 cm.).
112
TBE RFriECT OF TBR B1»DER
Kobrer's meastiroments moetly show larf^er dimeiiBions
than those of Mr. Pratt.. This maj be duo to racial pecii-
liaritiea in the patienta, tat I think that the factor which
IB probably paramount in explaining the diSereuce is that
Eehrer's patients came from a small town and its rural
neigh bonrhood, while Mr. Pratt's had many of them been
brought np in the poorer parts of London.
During the lying-in period these measurements dimi-
nish. The following figures show the average lessening
in 129 patients.
AfUr
(UUTorj.
irtertoii
wetk.
DiminQtiinL
At level of ^naiforn cart>l»g«
Sfidway between eoBiform ciirti1ag;e
At level of umbillou . . . .
89-S
8089
80-91
S8
80-6»
1-a
1-S6
1-S6
Thi& diminution of the circumference of the parts bound-
ing the abdominal cavity eeema to me such aa might be
expected from the reduction of the volume of the abdo-
minal contents which must accompany the involution of
the uterus.
The next table exhibits the difference between primi-
parte and multiparas ;
DajttftDr dBtlTcrr.
Mtet finl ncek.
DiBiiiiutiQa.
Prluii-
liani!.
Uultl-
Frinl-
[■UK
Mnlli-
puw.
Priml-
UtUU-
At level of CDsiform cartildge
Mid^ray botwecn umbilical
and GptifariD ciTtiUg^e
At level of ambiliciu .
29-2
29-3
80«
28-27
so-e
ai-16
88-1
28-1
87-9
S9-8
2fi-8
1-1
MS
I'S
X»
1*8
D-UEtNO THE LYIKG-IN PEIIIOD.
113
The differeBCB between primiparie and mnUfpane is so
small as to be practically nothing. The lower meaBiire-
ments are rather greater iu muUipnrfe, the average being
probably rtiiaed by the greater number of fat patients ia
maltiparffl. What little differonco there is in the amount
of dimiDation is all in the same direction, and ehows a
greater amount of diuiitmtion among the multiparic.
The next table shows what difference there is due to
age:
Dif liUrildlvinj.
Afler lint weak.
DiniinutlDB.
Dndiii
29-2
Ota
S6.
Undor
3g.
Over
n.
tluder
Otbi
M Wvel oC ontifonn urtiU^
SO
Sfi-OS
SS'SS
1-13
1'12
MidwRj between ciuifurm car-
2fl-2
29-8
2t-6
2S'6
1-B
1-8
At tnnliiliciu . . . .' 306
ai-5 23-1
8!>-8
1*5
17
Here we find the nieaBurements, as might be expected,
rather greater amoug the older pntients. The diflerencee
in the atQOunt of diuiiaution are not greater, and arc not
rogntarly distributed.
In order to ascertain what part, if any, the binder takee
in producing or modifying these changes in the size of the
chest and abdomen duriug the lyiag-in period, the follow-
ing method was adopted.
First, a number of patients, taken withont eelection,
were measured, as to whom no special instniotiona were
given to the nurses. They were allowed to put on the
binder in the way enjoined by the rules of the hospital.
The following are the directions giveu to them^ :
"The biudrr should consist of huckaback towelling,
thirty-«is inches wide and one and a quarter yards long,
doubled lengthways. Its lower edge should reach four
inches b«low the top of the thigh-bone (great trochanter).
114
THB Smcr OF THE BINDKE
The free end of the binder should He uppermost on the
right Bide. Starling from the left flank, the binder should
psEa over the abdomen, round ths bade, and »gaiii over the
abdomen, ending on the right flank, where, bfter it has
been tightened, and all creases smoothed out, it ahoulil be
aeonrely fastened by four atrong pins. The patient's ekin
should be guarded by the left hand beneath, and the pios
inserted in the following order, beginning from below — one
at the lower edge of the binder, three inches below the top
of the thigh-bone, and a second a similar distance below
the top of the hip-bone, both fastening the hinder tightly,
serving to keep it in positioD and preventing it from riding
up. The third should hold the biader still more firmly on
a level with the top of the womb; and a fourth near the
upper edge of the binder, not too tightly applied, complete
the serioB." Forty patients, to whom the binder was ap-
plied in this way, were mo&Eared.
In a second aeriea of patienta, thirty-five in number, also
taken without selection, no binder at all was applied, or
if a patient were discontented at its abeence, a binder was
put loosely roand^ care being taken that it should not be
tight.
In tk third series of cases, instructions were given that
the binder should be applied as tightly as possible, and the
house-surgeon at each of hia visits made a point of ascer-
taining that it was tight, and of tightening it to the atmost
of hia power if it were at al! loose.
TheBG three classes of patients are denoted in the tables
which follow, as those with ordinary binder, no binder,
and tight binder.
In these, and tn the measurements in which patients of
different ages were compared, the greatest differences are
between the abdominal measurements. It is in the
measurements of these parts that the greatest variations may
bo expected to occur, not only from the varying amount
of gaa in the bowel, but from the looseuese of the parietea,
which renders it easy to make the measurement half an
inch more or tees without a groat difference in the tight*
1
^^^^^^ DUBIKa THE! LTINO-IK PERIOD. llS
VaiienU wiih orHina.'nj binder (39 iu niimh^r).
^H
McHunmciils.
Afler
•tta.
DiminnliiiB.
I. At etuiform curtilnge
t, Uidwny Wtween eniifariii I'urtilugo
and umbilieai ....
zy-s
31 '6
S8-S
88-6
29-9
1-1
1-7
k
K Patimts without hinder (S5 in numler).
HaMBmnatiUi.
itta
dsUTOiy.
Sine ian
bfttt.
DiminutiDU.
L At QtuifariD oartilajtp .
S. Uidwftir iMtwreii onuifurin cartiliMcii
itnd umbllicn* ....
29-3
29-2
SO'I
SB-l
S8
S9-4
1-2
1-2
0-7
k
H Patient* with firm hindfr (48 w nitmher).
'
Utimireniciii*
After 1 Nine djijt
dtfUxerjr. mtiat.
1
OiniiiDllDu.
J
1. Al fnnirariD cartilm^
2. Midway between eniifofni eartilH^^a
andntnbilieaf) ....
S8-9
1S8-S
89-5
87*8
27-8
2fl
It
1
0-S
1
I ,
J
U6
THE RvrWT Of TH£ BtNDXS
neB8 of the measure. In the two circumferenceB, wliioh
are easy to lueaaare and do not vary from hoar to iour, tlie
figures show that the diminotion during the lying-in period
was the sarae, whether the binder were applied firmly or
loosely or not at all.
MeaBuremeutB have also been moide for me by Mr. Fowler
and Mr. Pratt, to ascertain the extent to which the lower
part of the cheat could be compreaaed by the measuring
tape. The amount of dimiuatioQ practicable in the majo-
rity of cases was between 3^ and 5 inohes. The maximum
diminution observed was 9| inches. (This was in a patient
aged twenty.three, who measured SSJ inches round the
lower chest, reducible by compression to 29.) The amount
of diminution ie 80 much iuBuenced by the extent to which
the patient lends herself to ib by relajiing the mu&olee
which expand the chest, and also by the amount o£ pull-
ing, that I do not think the compilation of averages from
theee figures wilt yield results of value.
The general conclusion that I come to is this : That con-
sidered as a means of keeping the waist small, a binder of
the ordinary kind has not the slightest effect.
I do not question the comfort it affords the patient, nor
argue agaiust its use as a means of giving comfort.
I do not doubt that by the pereistent nee of an onyield-
ing belt, which can be pulled tight and kept tight by straps
and buckles, the base of the chest may be compreaaed
during the lying-in period as well as at other times, and
that by the sufficiently prolonged use of such appliances
permanent deformity of the chest may be induced, or de*
formity preiseut before pregnancy maintained.
Di'. OBEVta Gdid that hu bad not found that putionte desired
a btlt from any idea that it could inSiiencc thf anc of the waist,
Thev wished for a belt bpcause of the support which it gave
to th>3 Iow«T abdomen aad for its effect in checking any future
tendency to undue fuliiees. He certainly thought also that, if
the belt were adjusted at the begiiiuing of labour and tightened
team time to time during its progrese, tt had a diBtinct iiLfluenc«
DDfiINO THI LTINO-IN n&tOti.
117
in promoting uterino action and lesaening any touduacy to sub-
sequeat beemorrboge.
Dr. Chamfnetb said he was unable to agree with I>r. Herman's
coaelosioQ that the only use of the biinlorwas the comfort of the
patient, anlesa th« word comfort were allowed a very wide eu^pe.
The usee of the binder were best exeiuplified by the occaaioual
consaqueneea of its absence, — in a word •' pendulous belly."
Bendolous belly was not a mere Eeathetic defect, but a condition
asBOOated with serious tods of health, and with diatressing aym-
ptolDB. 8Ucb aa constipatiou, pain in the abdomen, and other
thin^, and he belicTcd that the pendaloua belly was the cause
of the symptoms and uot merely an effect due to a cause common
to both. The UHe of a binder was to keep t]ie abdominal walls
in a favourable condition and position during th^ iurolation
which they, in common with other etmctures hypertrophied
during pregnancy, should undergo during the lying-in peiiod.
The 8ofl parts of the pelvia underwent similar hypertrophy and
similar inrolution, and, in their case, the recumbent position
aUoved them to undergo this in a proper position, wiiilc the
action of gravity (too early getting .up) interfered with this action
and promoted descent. Aa regurded the "figure," that, no
doubt, meant one thing in the cuae of a woman whose reputation
depended npon her being able to get into acventeeu-iiicli slays,
and another thing in the ca&e of a sensible doctor. The latter
probably meant a well-braced abdom«u, With regard to the
Oompreasiou of the hypoclioudria, Dr. Cbanipueya was glad to
hoar that this could uot be brought about by the binder, but Im
thought that A binder should not extend so high as to coiii]>ri;t8
the hypochondria. Binders were not commoniy used in (Jermuuy,
and, in bis experieuce, Eugliah hospital patients recovered with
hotter figures thaa German women, while private patienta who
had eiperieoced English and tierman oustomti preferred thv
former. He i^uite agreed with Dr. Hermnn that the bindi^r did
not prevent flooding; thu uterus, if incliued to relax, disregarded
the binder.
Dr. Braxtom Hicks referred to a paper published in the
• Proceedings of the Medical Society ' some few years siDce, under
the head of Variations of Abdominal Tension, m which the ques-
tion of the binder had heen alluded to, and other poiiits fully dis-
cussed. But be oould not thoroughly endorse tiiestateuKiiuts of
thfl previous spoalrers in regard to the UBeleasneas of the binder
on the ba»(.' of thorax. It wils cleiLr, from the facta collected by
the author, that the base of tbe thorax was expanded by the
pregnant uterus. This being bo after delivery, the abdominal
walln were unable by so much ae they were elevated to apply
their pressure on the abdominal contents — blood therefore flowed
into tlio abdominal cavity, ready to flow into the uterine cavity
■LouLd the walls of this oi^an become atonic. Dr. Hicks com-
118
THI SmCT OF TSa BINDBE, BTC.
pared the state of the thorai after delivery to that a/t^r flxpan-
aioa by very large oraxian cysta, where, aifcer tapping, the baa©
o£ tlie thorax waa so expaaded that, until a firm strap had been
applied around the patient, she waa uDa3)le to breathe or cough.
Hethought that if the thontiwero brought to its natural size by
a slight bauJage, it would be benefidal-
Mr. Alban Dohait renutrked that Dr Herman had not defined
what waa precisely understood by the term "waist." la the
days of Queen Elizabeth tbe waist of the drees wa.s as low as
the hipa, the body being joined to the skirt almost along the
line of the cniml arch. At the beginning of this century the
waist lay nearly as high as the axillro. What women really and
naturally objected to, after child-bearing, was eala.rgeiuen.tof the
abdomen which looked unaightly whererer fashion might place
the "waist." A pendnloua abdomen suggested mature years;
moreover, it gave rise to much physical discomfort.
Dr. HoBUAN said that his statements only applied to the
binder in ordinary use, put on, as was usiiaJ, after labour, and
not to the abdomioal bandage as an adjuvant to labour. By
" waist " be understood the smallest circumference of the trunk,
and this he thought in the preseat style of dress lay usually over
the lower ribs. Although attaching weight to Dr. Champneya'a
impreBgion as to tha grejiter frequency of pendulous belly in
Qermiui women, yet he did not think tb^it it bad been proved,
or was absolutely certain, that this greater frequency did exist.
If it did, it might be accounted for by other conditions besides
the absence of the binder. Women were commonly discharged
from German lying-in hospitals sooner than they were in this
country, aad possibly resumed their boueeh'^td duties sooner. He
could not see how, while the patient was lying in bed, there could
be much strain on the abdominal muscles either from gravity or
any other cause; and it was while the patient lay in bed that
the biuder waa worn. He could have understood the efect of a
belt worn after the patient got up m prtivonting ponduloua belly ;
but that woe not here under consideration. His figures showud
that the binder bad no appreciable effect in the abdominal
measurement. It was not his wish to dissuade anyone from
using the binder. Dr. Herman believed that the comfort that
it gave was a sufficient rea&oa for using it. But the binder was
not necessary, and was not a safeguard against any subsequent
trouble ; and he thought that medical men might be guided as
to its iwe entirely by the wishes of their patients.
Dr. CB&MPHEVSHaid that he bad not alluded to gravity except
in regiird to the pclviu organs.
APOPLEXY OF THE OVARY; CYSTIC DILATA.-
TICK WITHOUT RUPTIJEB.
By Alban Dohan.
mtOMK TO THB SUUSIZaV nUB UCMnTAL.
(BflMiivod Novembar SLst, 1889.)
[Ahilrael.)
Th8 patient was 34 years old, and had borne ei^bt children.
The alHlomcja vraa uuusuallj diBtended duriog her seventh
ppegnanty (1886). It riiiiiiUDfsil large till the conclusion, at
term, of her eighth preguAQC^ !□ th« eummer of 1888. The
abdomiual distention continued. In April, 1889, she was sud-
denly attacked with severe pain over the right B.ide of the
abdomen. Four weeka later the abdomen was found distended
by a globose, elastic and truely movaable tumour, which pressed
dowDwards into Douglas's pouch. Early in S<.*pti<mb^r the
tumour suddeoty diminiahud in size, sinking into the pelviB. On
October 2Srd Mr. Kuowaley Thornton operated. The tumour
woa romoved ; it proved to be thw right ovary converted into an
oral body, two and a half inches in its longest diatUBter, and
with an irr^nlar surface of a uniform dull drab colour. The
ntonuftud left orary, the abdominal vificera, and the pentoneuin
showed no sitfua of disease old or recent. The ovary formed a
cyst fiU«d with a ytillow mass, which was found to be old clot.
A Urge, woll-form»d corpus luteum opened out into the cavity
containing tbo clot. The cyst'Wall, one vightb of an inch thick,
consulted of normal orarian tissue bearing a few follicles. The
patient oiade a good recovery. The attack of pain in April, 1889,
probably roprosonted the nipture of a, mature follicle into tho
stroma. The ovary then griuluaUy distended till the hnmorrhage
oeas«d, and diminished in bulk as the clot contracted.
^
120
APOPIBIT O? THB OVAEY.
The varieties of apoplexy of the ovary are described. Thia
caae IB &a example, uot of hemorrhage confined to tli« cavity of
a dilated follicle, nor of htemorrbage ori^atiug iu tho etroma,
but o£ hismorrbage into the stroma through rupture of a follicle.
Mra. 0. C — , aged 34, a healthy -loolciug woman, short
in stature and inclioed to corpulence, was admitted into Mr.
Boiowgley Thornton's warda in the Samaritan Free Hospital,
in October, 1889.
She had been married for eeventeen years and borne
eight children, the youngest was over foarteou moutlis
old. The catamenia appeared at fourteen if not earlier,
and continued regular except during pregnancy and lao-
tation. In the course of her seventh pregnancy, in 1886,
the abdomen grew unusually large, bub she suffered no pain.
On September 9th, in that year, she gave birth to a very
large child and a "false conception" aUo came away,
according to her doctor's Etatment. On recovery she felt
quite well, but observed that the abdomen was almost as
distended as when pre^nnnt at full term. One yeai' and
ten mouths later the patient gave birth to a smaller child
(her eighth), Tliroughout this pregnancy she was never
as swollen as in 1886. After delivery, the abdomen re-
mained distended!. In April, 1 889, ahe was suddenly
attacked with severe pain in the right side of the abdo-
men, and called iu a practitioner. At the end of May
Bhe conaalted Mr. F. W. Morisoo, stating her behef that
ehe had a tumour and was as big ^ at term. The size
of her abdomen prevented her from doing heT household
duties and defeecation waa painful.
Go examination, the abdomen was found distended aa
at about the seventh month. The umbilicus protruded.
The hypogastric and umbilical regions were occupied by
B globose, elastic and freely moveable tumour, dull on per-
cussion and " distinctly fluctuating." The right flauk
WH resonant, the left dull on percusBion. The cervix
uteri was high id the pelvis uud pushed forwards. The
poaberior fornix was ocoupied by a rouud, olastio swelling.
APOPLEXY OP TSr OVABT.
121
convex towards the vagioa and continuous with the abdo-
toinal tumour.
Early in June the patient was taken, to the Kamaritan
Hofpitalj where Dr. Amaud Iloiith and Mr. Thoratou exa-
mined her. OrariiiQ cystoma was suspected. She re-
turned homo, to await hef turn for admission into the
hospLtal. At the liegiiming of September she infoTtned
Mr. MorisoQ that a few days previously she discovered, on
getting out of bed, thfit her abdomen had suddttuty dimin-
ished in size. Mr. Morieou^xauiiiied her, and found that
the abdominal tumoar had quite disappeared ; resonance
was uuiversal within its normal limite, and tlia abdominal
iralU were flaccid. On vaginal examination, a mass the
aizd of a billiard-ball was felt high up in the region of
the right broad ligament. Tbia maaa was QOt tender to
touch, and caused no pain. The patient's health steadily
improved.
The patient was admitted in October, just six monthi
after the sudden attack of pain which, as the sequel will
ghow, probablv represented the beginning of her illness.
The clmical history was complicated, jet most important
in relation to the pBthnlogy of the case. Fortunately,
Mr. Mnriflon preserved the notes which ho took during
the progress of the patienfs illne^ft, and kindly sent me a
copy, of which I have availed myself in the above report.
The remainder of the case camo under my own observation.
On admission the patient's abdomen whh found to be
digtcuded by fat in the parictos and by Sntus, but no
tninour could h& detected. There was tendovnesB over
the iliac fosste. The os nteri was large aud flabby, the
sound paiasedinfor two and a bulf I»che8. Ou the right
side and in front was a mass " the »izo of a smull orange,"
freely moveable and tender. The last period began on
September 23rd, 1889.
Mr. Thornton opornted on October 28rd,and I had the
advantage of atJeiKtiug him, eo that I was enabled to note
the relations of the tumour and the condition of tho parte
exposed. An incision thrco and a half inches in length
VOL. xxziu 9
122
APOPLKXT OF THB OVAFY.
was made through fat parietaa. An oval body was at once
drawn ont of tlie incision witliout any difficulty^ ae there
wereno adbesioDB. This body liad a singular appearance,
Bomewhat reeembliug a boiled suet dumpling, and at lirst
was suspected to be a pedunculated subperitoneal fibro-
myoma, but its pedicle vvils found to consist of the right
Fallopiai) tube and broad ligament. The uterus was large
ftnd soft. The left ovary was healthy and succulent, and
contained a large ripe follicle ; it was not removod. The
parietal and riseeral peritoneum appeared perfectly normal.
The patient luado a good recovery.
The tumour consisted of the right ovary. It weighed
two ounces, and measured two inches and a half in vertical
diameter, and one inch and five-eighths horizontally. The
surface was of a dull drab colour, and puckered eo as to
present convolutione like the brnin of one of the lower
mammalia. This appearance is not rare in the big succu-
lent ovaries of healthy young raamed women. When
cut across, the interior was found to consist of a spongy
lemon-coloured Bubstanee, the ovarian tisaue foiining a
cortex one^eighth of an inch thick. The cavity contain-
ing the substance bore a translucent lining membrane ; at
the uppermost part, nearest the attachment of the bvnad
ligament, wan a thick piece of membrane forming Bigzng
folds, evidently the remaius of a large corpus liiteum.
TIlh appearance of the interior of the ovary, as seen when
the specimen wae fresh, iawell represented by Mr. Lewin's
coloured drawing.
The brond ligament bore an acocBBOry fimbria on a long
pedicle, which had become soparntod from the Fallopian
tube. Two Graa6aii follicles projected from the surface
of the ovary near llie iitLaclmient of the broad ligament.
Both were much dilntud. One, half an inch in diameter,
contained altered, almofit decolourispd clot ; tlie other,
one-third of an inch in diatneterj contained white, slightly
glairy fluid.
After the coloured drawing of the specimen had been
taken, the two halves made by a section to expose tho
APOPIiBIT or THE OTART.
inierior of the ovary wore placed for a few days in a weak
Bolutiou of spirit. At tlie eod of that period I found an
opportunity of GxamiQiu^ the specimen more iiiiuutclv.
A large, Bingle-ctambered cavity occupied the ioterior of
the orary. It was filled with the tougli yellow Bubebanco
already described. The membrane in zigaag folds was
deficient towards tlie yellow Bubstanee, bo that it partially
enclosed a space (roBembliDg in all respects the cavity of
a well-formed corpus luteuin) which, where not bounded
by the membrane, opened out against the yellow suhistanee.
On removing the substance from the cavity in which it
was embedded in one of the half-sections, the space par-
tially enclosed by the zigzag membrane waa found to
7en out into that onTity. The above appearances indi-
cted the rupture of a mature follicle into the stroma,
with sobsequent hemorrhage.
The lining memhrane of the cavity which contained
the yellow sttb»taiice, translucent when fresh, became
opaque after the immersion in spirit. The meuibraue
was soft aud homogeueous ; it was apparently haU>or>
ganised fibriue. Mr. Targett carofully esamiDed the
yellow Bubatance, and found that it consisted solely of clot,
with no appearance of oriranization. The general appear-
ance of the diseased ovary and the relations of the corpus
luteum to the cavity indicated a pathological ooudition
which bore no relation to incipient cystoma of the organ.
No rent nor cicatrix of a rent, nor any aperture nor
fifltuloits track could he detected on tlie surface of the
ovary. The two dilated follicles bore no cicatrices.
The appearances above described render an esplana-
tioQ of the clinical Kymptoms simple. I attach but little
importance to the history of the patient's seventh and
eighth pregnancies. The sudden attack of pain in April,
1889, indicated the rupture of a mature follicle into the
ovarian stroma. The conseciurut dislentioQ of the ovarj-
would necessarily entail much Buffering. Through some
obBcur© cause, probably morbid softening of the stroma,
hfcmorrhage took place and continued for some time nn-
124
APOPLEXY or THE OVABIT.
cljecked, Tha ovary became Bwollen ao aa to form a
tuTUOLir apparently tlie size of a fcetal head.* The Biirface
oi tlie ovary failed to burst, the hiemorrhage ceaaed, and
therefore tLe distention ceased. A coagulum formed
witLin the ovary and contracted, so that tlie pain dU*
appeared and the swollen organ steadily became enaaUer.
Thus the appearance of a tuuiour in May, 18S9, Homo
time after the attack of pain, ia. readily explained. The
tumour was tlie ovary. It could not very well have been
blood-clot free in the peritoneum. Ruptur* of the right
ovary seems out of the question in thia case, and hiemor-
rhagc from a burst follicle in the left ovary may be Bet
aside. Free bleeding into the peritoneum would have
caused faintuoss rather than aevere pain ; but the patient
laid stress ou the fleverity of the pain in April, and does
not appear to have felt faint. At the operation the peri-
toneum showed no abnormal appearances of any kind.
Had the tumour^ detected in May, consisted of a large
circumscribed collectiou of blood in the peritoneum, some
trace of tho effiiRod blood would certainly have been found
during the operation ia October. There remains no other
explanation of the tumour which appeared in the spring
of 188i>.
The specimen illustrates the condition knowu to patho-
logists by the oonveniect name "apoplexy of the ovary."
Authorities bo high as Beroutz and Goupil have already
ju&tified the nse of that term. They speak of a hsemor-
Thagic softening which resembles a similar condition pre-
ceding cerebral apoplexy. The term "apoplexy" is gener-
ally intended to imply rupture of the ovary through the
hsemorrhfige, but Wiiickel, one of the latest writers ou the
subject, applies the term, in his ' Diseases of Women,' to
the earliest or mildest forms of the condition in question.
" The hypertBUiia of the ovaries which accompanies men-
strual congestion may be so greatly increased by external
causes that not rarely a follicular haemorrhage as large as
* Th» sbdouittml wnlLi uere tut, lo tbat tlis tumour probnlily felt larger
lliati it rrnllj was.
125
a cherry may be found in the ovary, This apoplexy may
affect a number of foUicUs simultaneonsly."*
Ovumn apoplesy with rupture neoeasnTily iavolvca
lifBuifttocele. It is a rare and very fatal condition. Dr.
Matthews Dnnofin informs me, " I httve s»eu a fatal case
o( burst ovnrinn cyst, do bigger than an orangQ. It never
came to a formed bBematocelo, as tho woman was found
dead or just dying. HoMuorrhage evidently made it
burst. " The "cyst" was apparently of the same cha-
racter as in the present specimen.f Bernutz and QoupilJ
describe several cases of ovarian apoplexy with rupturcj
but the clinical reports {repeatedly quoted by British and
American writers from those two authorities) arc second-
hand, and suffer SBrioualy from want of diagrnma. These
remarks espGcially apply to Puech's case, which occurred
in days when not only tlio pathology, but alsothdauatouy
of the ovary were very imperfectly nuderstood. Indeed,
Bernutz aud Ooupil display a wholesome scepticism on
some of the pathological reports which they publish. In
all the cases which they quote, however, there wns clearly
rujiture of the ovary from heemorrhoge.
Ovarinn apoplexy without rupture, as in the present
specimen, has been well described by Wiiickcl aud
' i^iiicc this |inper nui written laf itttoutlou hai boon tariicd lu u good
■atnmur; of ll>c wliplo aiibjoct of gvuiiitii liicinotTba^c Kij' Vt. F. JtoUiu
(' H^inarrlingiM dci OvwrM," Piirm, HU-iiilirit, 1889).
t Sco alto ft MIC recorded by Dr. W. Brourii, of M«lrOM, trhoro a woman,
afftA id. ilii^il «uiJJ«iily on ttio ovo of her marring^. Tba hiuuiorrliiteu ws«
tnwed to the left ovary, whivLi wai " Dunrly tliu Kiio of a tiirkpy'R egg"
('Bdin. Ucd. •Tourn.,' vol, i, 1856-6, y. Si'i). Still luorv intcrulinifi in
rolntinn to tli« i>r«ieiil caw, !■ Dr. AleiandfiT T)ioium)ii'« " Noti^ of it Ciuu uf
Itoptwo of ill* OvBry folbwinj Abortiaii " (ibid., vol. iv, 1868-fl. f. 6(H),
Tilt patient wm forty ycnrx oI<I, anil nbartud nt tlir m-rond month. TlircL'
if«vhii tntt^r tymptomi of intra -peri Ionian I bnmorrha^ oecurrod and prav(^d
tiUl. "Tliu riicbt orary wm found to liuvc iia^tiiinod a tiauar rupturu
tbrou^out it* entirp Icii^h. The ovHry wn» isut iticri-iued in length, and its
tcxlarc uppcnrcd bcnlthy, with tbe osovption of alight indnnttwa ut ono
cstiVDity."
{ ••Clinical Mcnoif* on the DitniuM of Women," Dr. Mvndow*' trsuiU-
Uon. Now ijydcDbam Society, 1S60, vol. i, p. IfW.
APOPLEXT or THE OVAKT.
OUhanseri. The forraei- has observed great dist-ention of
the follicles from effaaed blood without- " any extravasation
of blood into the stroiuft " iu three aubjeota after death
from petroleum. burns ; in two after phosphorus poison-
ing ; \-o three after typhoid fever ; in one after cerebral
apoplexy ; oue after tuberculosis ; and one after death
from cardiac diseaee.
OUhauaeu, in his exceUent 'Krankieiten der Ovarien,'
divides ovarian apoplexy into two varieties^ hEsmoiTbage
into the follicles and hsemorrliago into the stroma. In
pare examples of the second variety, which follow local
congestion and are seen as complications of scurvy, typhoid
and other fevers, the stroma becomes converted into a
spongy snbetaace full of fluid blood, roaembliug the
spleou.
Th« present specimen, as proved by the appearances
which I have above described, is an e:(atiLplc of ovarian
apoplexy originating in a follicle, but involving the stroma
through rjptureof the follicle. Olshausen, who recognieee
this secondary form of haemorrhage into the stroma, de-
scribes an apparently similar case. " Whilst small apo-
plexies disappear, as a rule, through reabBorption,Bnd leave
no trace behind, large effusions may lead to the partial or
complete destruction of the parenchyma,* involving in the
latter caso the convuraioii of the ovary into a single cyst,
Qlied with a thick, greasy mass. In the courae of a
necropsy I recently came across this condition by acci-
dent. The ovary, lying in its natural position, was aboat
three times its normal ^ize. The outer wall waa thick, no
tiace of the stroma remained, and tte contonta formed a
very thick, greasy, browniBh-yellow mass."
Hiemorrhage into the follicles, Olshauson's first variety
of ovarian apoplexy, must often be overlooked. TJnless
every Follicle be involved, it ia hard to believe that it
necessarily destroys the functions of the ovary. Heemor-
* OUhauacii tlooa iiot Atuto wli«t)iur tliii ia caused by pTonturc of tbe blood
within an unruptured folliRle, nr bjt I'ttniTnBn.linn Into tlic itrDmn, lu in th*
tnutoat cuk.
APOPLBST 0? THE OTART.
127
rhage into the stroma is more serious, and may end in
rupture of tTic orgaij. The present specimen represents,
therefore, a relatively mild and secondary type of that
variety of apoplexy ; yet at an early Btago of the case
ruptnro of the ovary must bave been imminent. Ovarian
apoplexy is uodoubtedly uue of the chauges [if not the
principal ohange) which destroys the functions of the
oruries during attacks of certain acute diseases already
epeciGed.
Dr. AjtfAHD RocTH could not agree with Mr. Dorau's csplan-
utioii of tbiei viiae. In May, 1889, the tumuitr was a. Iluctiuiting
vyBt, leiicbLui^, as bimanual palpation plaiDljr iudicnted, from
Douglas's poiacli to tho uinbUicTia. In September it suddenly
diminished in eine; itnd wbon bo aavr her tigaiu. early in October,
only a hnrd body tbe size of a amall orange could be felt. It
mu difficult to )>)'lieve that the (lyat was iLt its origin entiri'ly of
tbti nature vi illi apoplectic ovary, or that if it had been an
ordinary ovariiLo cyst it coidd have undergone epontaaieous
resolution. He believed that tbe hiatory iudi>i'ated that the
origiual tumour was a.u ovarian or broad ligament cyal which
ruptured in .Sbiit^^uibcr, ami ibat tbe cbaugta- described by Mr.
Uoran aa baviuf^' eocurred in the ovury took place BubsL-qneutly
to tbat date.
Dr. HoBROCRS thought that the term apoplexy was good,
although flyiuo logically indefensible. But its meiining should
be analogous to thiit implied when used for other reciona.
Henw it ought not to be coHfiiied to those tiaaes in which the
iurfuco of the ovary was ruptured, but should mean hiBmor-
rbage into a U'riiafiau follicle, or into the stroma of the ovary
vith or without rupture of the surface. Mr. Albii.a Dorun had
drawn attention to tbe great paiu alt«ndiug tbia case, and had
explained it by the distention uf the organ. This was probably
correct, but Dr. Honrocks pointed out that paio in the ovarian
region did not nece»sarily mean ovaritis, as some pbyAiciana
seemed Lo tliiuk. Indeed, in other viseera it wms generally tbe
capsule that was affected wbcu paiu was a prouiiaeut aj mptom,
whilst indamination of tbe substance of tbe organ was painless
or nearly so. He mentioned pleurisy and pneumonia, uienin-
citis and cercbritis, perihei-atitis and hepatitis ag oiamplea,
He thought tlmt iipopleiy of the ovary was not bo uncommon
as might be suppiosed from examinations in the dead body.
Dr. CoLLlMowonTn was sorry that the t«rm "hr&matoma"
had not been used instead of "apoplexy." The former, being
alreadjT employed in tbe case of htemorrbages into the connec*
AFOPLBIX Oir THE OTABT.
live tiasue of the broad ligament, was perfectly ffimiliar, and opcii
to leaa objection ou ruuiuj- grounds. He did not think thiLt tin:
aulhor's exjilana-tiou of the cliuical jiheuoiueuu. was altugether
convittcing. The sudden diminution in size of so huge a tumour
eeemed to point to rui>tute mtbor than to gnidual absorption
within tht> tumour itself. That no sign of such rupture existed
oith^r ia tho walk of the tumour or in the i>enU>nen.l emvitj did
uot disprove it. The cxtravusuted fluid might have bceu of a
simple sero'Ua nature, such as would easily undergo a.bsorption.
Wir.il repaid to the cbauges that the autlior aJtuded to aa taking
plucv in the uv&ry after hasmorrbage into its pariiucbytua, he
(.Dr. Cull ill )pr or til) hud lat<rl7 met vritli such im iiistauce as hod
heen described ia the case of a youny woman of twonty-threi?,
upon whom abdominal amotion was performed m December last
for a parovarian cyst of tlie right side. When, in the ordinary
routine, the appendages of the other side came to be examined,
the ovary could not at first be found. It was evuntuaUy die-
covered completely wrapped up in, and adberuut to, omentum,
a portion of which was removed, with the ovary within its fo}ds.
The ovary waa represented by a mere shell containing dark
brown pidtaceous material, evidently altered blood. It bad
uudergoue uo increase in size, but had heeii pulled upwards by
the omentum some diBt-anco away from its normal position.
The Fallopian tube and broad ligament on that aide were quite
healthy,
Mr. DotUTT, in reply, stated that ftmall extravasations of
bbod into tho foUiclea and substance of the ovarie* wero pro-
bably froquent. The big ewetlingA, full of blood, not rarely
seen on the surface of the ovaries of healthy young Hulijecta were
often normal, the healthy ovary and ripe follielea being much
larger than was geuerully bi-licvcd. As mL-dical men first studied
the ovary in the dissecting-room, where specimens of that or^un
were usually atrophied, thty often carried false ideas of tha
ovary tbroughout their careers. Mr. Doran had giveu full
reasons why the original swelling could hardly have been a
" cyBtoiua " in the preeise pathological seuB» of the word. The
dlaguoeis made by I>r. Amand Kouth, Mr. F. W, Moriaon, and
Mr. Thornton was clinically quite correct, for the tumour, a
swollen ovary filled with blood, certainly formed a cyst. The
appearances of the peritoneum and viscera at operation proved
that no ruptureof the ovary or of any cjut or blood-vessel could
have recently taken place. Extravaitation of fluid into the sub.
stance of the ovarj', inEauimatory or otherwise, caused great
paiu, UB iu orcbitis and iiitra-ocular inttamiontion, where organs
with tough cnpflules were involved, Dr. Cnllingworlh's caaeof a
small eyHliuH])Oplectic ovary found adherent nud en tangli>d in the
onientum, high above the pelvis, reminded Mr. Doranof aetmilar
ca»e described in his paper " On So-called Non-ovariiui Dermoid
APOPLBXT OP THE OTABT. 129
Abdominal Tumours " ('Med.-Chir. Trans.,* vol. Ixxxviii, 1885).
This condition was akin to twisted pedicle, which sometimes
caused hsemorrhage into OTEirian cysts, and might be one (cer-
tainly not the sole) cause of apoplexy of an ovary free from
cysts. The walls of the ovary exhibited by Mr. Doran con-
sisted of solid ovarian tissue ; they bore no resemblance to the
walls of a true cystoma which had partly collapsed. " Apo-
plexy " was a convenient term. Perhaps " hEBmorrhage into the
ovary " was better ; " hmmatoma " was hardly as simple.
APRIL 2nd, 1890.
Alpkkd L. Gaij^bin, M.D., Presideat, in tta Chair.
Proaent — 53 Fellowa and 9 Visitora.
Books were presented by Mr. Alban Doraii, Dr. GiUabiu,
Dr. Minot, Mr. J. Kiiowsley Thornton, the Amerioau
AsBOciatiou of Obstetricians and Gyu:ecologists, the St.
Tbonias's HospitaL Stuff, the publishers of the ' Medical
Annual/ and La Society Obstetricale et GynScolo^ijne
de PariB.
The following geotlemeii were elected Follows of the
Society : — Augustus W. Addinsell, M.Ii., C.M.Bdin. ;
Goorgo Edward Anson, M.A., M.D.Caiitab-; George Clack,
M.B., B.S.Lond. ; Albert Ehrtuatin, L.R.C.P.Loml.
(South&m) ; Charles Arthur Morris, M.A., M.B., B.C.
Caulab., F.R.C.S. ; Frank Frederick Schacht, B.A.,
M.H.Cantab.; Hugh Smith, M.D.Loud. ; and Ernest
Alfred Suape, L.B.C.P.Lond.
The following gontlomen were proposed tor election : —
Arthur Henry Robiaeon, M.D.Durh. j and Reginald
Muzio WilUamt), M.D.Load.
182
LIVING FEMALE CHILD WITH THREE LOWKR
LIMBS.
By Clement Godson, M.D.
Db. Gomon eliowed a feiudle iiifmit born on December
SOtli, ISSIJ, iu tbo out-patieut Laiiteruity depurtmcut of St.
Bartbolomow'a Hospital. Tbo point of iutereet ia the case
was that sbo possessed a tbird log. At birtb the vertex
presont(.id, and there was no difficuUy in the delivery. The
mother had borne five other cbiidren. The third wna
an idiot and bad club-feet.
Mr. Albah PoBAif observed that some ninlforuiutioQs were
evident examples of dicbotouij. whilst in olber cases where
Kujiermiiiiemry utriicliit'ea were n.pi>eudGd to an otberwlsL' well-
formed infftnt, those structures repreaonted an acardiac twin
which had become attittbed to its brother. Dr. Qodnon's
Bpecimen was clearly due lo thu former condition ; whilst to the
latter (which Mr. Dorau had disf^ussed at length in a. pa]ier
Imbliehed iu the' Transactions," 1869, p. +) wits due the deformity
mown as epigiiathus. where the rudiments of a ftetua were
attacfai^d to the oral cavity of an otherwise well-developed child.
IuU.-riu«diate forms, however, existed, wheru ctaesitication under
either of tbi? abovtt kinds of malformatiou was not bo easy, eape*
cially when the relations of the eord to the fiutus and Ita appen-
dagQ could not be ascertained.
THREE CASES OP CONGENITAL DIAPHRAG-
MATIC HERNIA [TWO BEING ON THE RIGHT
BIDE).
By Hebbbet R. SriKOBR, M.D.
Case 1, — A male child, 21 inches long, weighing 6 lbs.
10 oz. It was externally quite perfoct. The mouth, buub,
oretbrn, and penis were normiil ; and the toeticlea lay in the
scrotum. Through a hole about one inch in diameter at the
CONOENEIAL UUPBSA.OHATICr BESKIA.
133
for©-p&Tt of tho rig^ht side of the diaphTagm a large piece of
the riglit lolie of the liver had passed, and behind this the
email intestiTie Rud the ccecum and vermiform appendix
had mUo prolapsed. The piece of liver had asaamedj
roughly, the shapij of the pleural cavity, and was conetricted
below by the smooth edge of the hernial ring. Its sur-
face was spotted over with bmall biackish-red haamor-
rhiiges, resembling Tardien's spots on the surface of the
lengs. The ri^ht luug was rudimentary and had never
filled with air. The heart, thymus, and left lung were on
the left side of the thorax, pushed over by the displaced
viscera. The left luDgwasof good size and had received
air. There was no sac to the hernia. The child wns
boro natarally, and lived for three quarters of an hour.
The p[>st*tt]ortem exaraiDation showed congestion of tho
liver and of the meninges of the brain, butnohfemorrhage.
Casr 2. — A largo full-term etill-born male child. The
deformity was on the right side, as in the precedinpcase.
It exactly resembled Case 1, except that the opening in
the diaphragm was further baek, and that (iu addition to
the email intestine, ca'cum, vermiform appendix, and large
pieoo of the right lobe of the liver) the right kidney
had also passed through the aperture. There was no sac
to the hernia.
Cabe S. — A Btill-born female child 20 inches long,
weighing 6J lbs. The diaphragm was entirely wanting
OD the left aide. The left eide of the chest was filled by
cnall intestine, the stomach and great omcntam, the epicen,
Ik piece of the left lobe of the liver of the aizo of the
top of the finger, and the rudimentary left lung. The
CDsophagns was constricted at the lower end. There Tr«
QO sac to (he hernia. After doalli, exteiiaive nipningeal
haBmorrbage was found over the upper half of the cortex
of both corvbral hemispheres-
134
CASK OP CENTRAL CHOROIDO-RETINITIS OCCUR-
RING AFTER LABOUR AND POST-PARTUM
HEMORRHAGE.
By H. MA0»AP9aT0H JONIS, M.D,
Dtt. Hackadquton Jokes showed an nplibhalmoBoopic
drawing (Bargoss) of " central choroido-retinal " disease.
The drawing was taken on March 4tli, the patient having
been delivered, with very severe post-pnrtum hfemorrhage,
on January 7th. The vision of the left eye on Febpimiy
20th was found to be reduced to counting fiugei-s at five
fe«t, and rea-ding 4-0 Snellen at three foet. The defect id
vision appeared on tlie third day after labour. There was
DO nlhuminniia during or after pregnancy. Tliere had
"been no previous visual defect. The vision of the right
eye was normaS. There were no cardiac complications.
The ophthalmoscopic appearances were aa follows. A
constellation of white dots was scattered over tJie area of
the macula, but not oUowhorc. The macula itself was
somewhat blurred in appoai-iitioo, and the whole uf this
region was marked by greyish-rod pnnctatioaa, whtoh
were also scattered hetween it and a somewhat white
papilla, with few and thin vessels. There was a black
crescentic (physiological) margin of choroid at the nasal
aide of the papilla. There were no vessels in the region
of the mnculn. Dr. Macnanghton Jones drew attention
to the rare occurrence of this affection, the dietinguialiing
features between it and the retinal cbaugos in Bright's
disease, its occurrence io one eye, and its association an
this case with labour and hromorrhngo. The Bimilarityof
the appearances here observed to those described by Mr.
Nettleship in "central guttate choroiditis " was striking.
The case was, However, more exactly allied to the central
choroido-Tetinitis of Mr. Warren Tay and Mr. Hutchinson,
the latter authority surmising that these " dots " miglib
EXTRi.-OTig&IKS OBSTATIOtf. 135
be of a colloid nataro. Tho Lsomorrhage Jiftd probably
led to chopoida! thrombosis which had caused the imtn-
tion, leading up to the rctiuitiB and these special "dots."
UTERUS REMOVED BY PORKO'S OPERATION.
By C. J. CotLINOWOBTH, M.D.
Dk. Ciii.f.iNOWOKTH exliilpitetl the ntems from a case of
OaeBareJiii section. After the introduction of tltc uterine
suturffi, persistent ha3morrhage from a divided sinus made
it necessary to remove tlie uterus by the method of Prof.
Porro. Both mother and child were saved.
FCETUS AND PLACENTA FKOM A CASE OF
EXTRA-UTERINE GESTATION.
By C. J. CDHiNowoRin, M.D.
Dr. CcLLiJiawoBTH idso showed n fally developed Ffctus
and placenta removed the previons day, by nbdorainal
section, from a case of extra-uterine gestation. The sac,
formed by the right broad ligament, was stitched to the
lower pare of the abdominal incision. Tlie operation was
performed exactly four weeks after the cesaation of foetal
movements. The removal of the placenta was therefore
commenced cautiously, but was accompliHhed without
serious hsemorrbage.
1S6
CANCEROUS UTEEI REMOVED BY VAGINAL
HYSTERECTOMY.
By C. J. CULLISQWORTH, M.D.
Dr. Cullinqwokth further exhibited, in illiiBtration of
his paper read tlio same evening, four cancerous uteri
removed by Yag^nal bjsterectomyj and fiye specimens of
Dancer of the uterijs from St. Thomas's Hospital Jltfaseam.
Detailed descriptions of the former were given in tho
pn.por (p. 141), and of the latter in an appendix (p, 164).
DISEASED OVARIES AND TUBES.
By C. H. CAfi-rsB, M.D.
THREE SPECIMENS SHOWING REMOVAL OF
CERVIX UTEBI FOR MALIGNANT DISEASE.
By Abthitb H. N, Lewheb, M.D,
Dn. LswBRa showed specimens from three cases of eupra-
vAginal nmputntiou of the cervix for malignant disease.
They illnstrated the class of caspB in which total extirpa-
tion of the uterus offered no advantage over the supra*
Tagiiial amputation.
In one, a specimen of crater-like ulcer (No. 4 in the series
published by Dr. Lewcre*), the patient remained well, and
free from recurrence for nearly twelve months after the
operation. Then recurrence took placo in tho pelvis late-
rally, at some distance (about one and a half iDches) from the
" ' Fnotical TetUlxwIt of tlio Dititiiti <if Women,' jad od., p. 426.
cijicBA or qppbb part of oibvix.
137
stump. This, and the part, of tlie uterus left behind, were
quite aaaffected by the malignant ^owth to tbe last.
Obviously, in this L-ase no good would have resulted from
total extirpation. In the eecond specimen (No. 12 in the
Beries) there was a cauliflower-growth, the size of half a
crowBj the patient was still qnite well and free from recnr-
rence at the present time, one year and teu mouths since
the operation. In another, the third specimen (No. 10 in
tbe aeries], where there was a largo cauUHower-growth
ohtefly affecting the posterior lip, the patient was three
months pregnant at the time of operation. Examination
of the specimen showed that there wag an ample width of
Wealthy tisane in the direction of the uterus, much wider
than the area of sound tissue laterally and towardn the
vagina. This patient waa atill free from recurrence ; it
was now nearly eight months since the operation.
CASE OF CANCER OP UPPER PART OF CERVIX
EXTENDING INTO BODY OF UTERUS, WITH
VERY LITTLE DISEASE TO BE SEEN OR PELT
BY THE VAGINA; VAGINAL HYSTEREC-
TOMY; RECOVBRYf RECURRENCE OP DIS-
EASE j DEATH THIRTEEN MONTHS AFTER-
WABDS.
B7 a. E. Hbumah, m.b.
E. T— , aged 46, admitted September lOth, 1887.
Began to menstruate when aged twelve, alwaya regular
except during pregnancy ; with pain ao bad as to lay her
up each month until child-bearing. Was married at
seventeen ; had twelve children and four miscarriage.'^,
tbe Last six years ago. No illness until the pi-Qseut.
The present illness dated from eight and a half montha
ago. Then the patient felt a sense of weight and unoan-
oees ia tbe right lower abdomen. A month later a yellow
TOL. zxzii. 10
186
CAHCEB OS UPPECK PAUT OV CXSTIX.
discharge began, and it continued fiioce, bnt had never lieea
oSflusire, tliough from the beginning often tinged with
blood. There was hBeinorrhage for three weeks before
adtnission ; the appetite throaghout was good. Bowels
costive, but no pain on defsecatioa. Pain not severe.
Patient stated that she had not got thinner. Weight 14 st.
bi lbs.
On admission the patient was florid and well nonriahed.
The uterus was moveable. The vaginal portion was healthy
exoept for a ring of excavating ulceration anrrounding the
oa externum, bleeding when touched.
September 16th. — Patient was anieathetised, with a view
of removing the cer?ix uteri. On careful examination
some induration was found in the left lateral fornix. The
operation for removal of the cervix was commenced in the
usual way. In cutting into the upper part of the cervix
in order to separate it from the body, it wbb found that the
knife went into a ragged cancerona cavity, which extended
up into the lower part of the body of the uterus. The
cervix broke down so readily that it could not be used as a
means of drawing down the body, and it was therefore
separated. The body of the uterus was then removed.
The Woftd ligaments were sacured by ligatures. Iodoform
was freely duated on the parts, and an iodoform ganze plug
put in the vagina.
I'he patient made a good recovery. The highest tem-
perature reached was 101 '8° on the evening of the third
day. After the fourth day it never exceeded 100*, and
after the ninth day waa noroial. On October 3rd, weight
13 St. 7 IbB. ; January 13th, 1888, weight 14 st. 5 lbs.
The patient died on October 22nd, 1888, from recurrenoe
of the dlaeaso; bnt as she waa not in hospital no details
of the lllnees, or autopsy, could bo obtained.
The specimen consiated of the cervix and body of the
atema. The vaginal aspect of the cervix was healthy ex-
cept that it was thickened. The o» extemnm was Iriangn*
lar in shape, and not larger than a threepenny-bit, and it
formed, aaseoa from the vaginal aspect, an excavation filled
»A01»AL BYSTEBBOTOSt,
189
with smftU warty growths. TLo part of the cervix tliat
had been attached to the body of the uterus formed an
irregular cavity lined with loose warty and villous growths.
These growths extended to within an inch of the fundus
uteri. In the cervix only a very small band of healthy
tiBsue bounded the growth peripheraHy. The body of the
uterus was enlarged, its wall being nearly an inch thick,
bat its cavity waa not dilated^ and its lining membrane
above the cancer did not show any microscopical changes.
The specimen was No. 2170 in the London Hospital
UQaeam.
SARCOMATOUS UTERUS REMOVED BY VAGINAL
HYSTERECTOMY.
By W. R. Dakin, M.D.
Db. Dacih showed a ntema whioh ho had rcmovod
Beventeen days previouoly from a patient aged 51. Sho
watt a widow, and had not meustraated for six yearti.
Six months ago she began to have slight hsemorrbage
from the vagina, and this had steadily increased till it
was profase and very frequent, when she came to the
hospital. She had do paiu and hardly any discharge.
Oa examiuattou the vagina was foand perfectly free
from growth, and the vaginal portion atrophied. The
position of the os was indicated by a dimple, and the
Hoger just entering this camo on a brittle, profusoly
bleeding surface. The length of the whole cavity of the
uterus was two and a half inches. The body was there-
fore somewhat enlarged. She was admitted and examined
under an antesthetic. The uteni.<4 waa drawn down, the
cervix curetted, and the body explored. The growth was
f<Mud to extend up towards the right comu. There waa
no deposit round the utenu, uud the organ was very freely
VAQINAL BTBTUBBiClOHT.
moveable, being perbaps sligbtly held wTien it was at-
tempted to draw tbe fundus far to tbe left. Dr. Dakin
then decided to remove the whole uterus. All her other
organs were found iioruial. She was douched for three
days before operation twice a day with a 1 — 2000 eolation
of sablimate, the vaginal walla being rubbed with the
solution.
The operation presented no difficulty ; the bladder "was
first separated up to the utero-vesical fold of peritoneum,
then Douglas's pouch opened and the broad ligaments tied
in sections, the uterus being slightly pulled down. Three
ligatures were put on the right side and four on the left.
There were no adhesions, and the surrounding tissues were,
as far as could be judged, normal. This took fifty minutes,
but after it was all done and the patient was just going
to be remoTed, she began to bleed profuaely, the blood
ooming fi'om somewhere high up in the left bread liga-
ment. Sometime was spent in loolciug for the vessel, but
as it could not be found, and the patient was losing con-
siderably, the pelvis was plugged with several yards of
iodoformed carbolic gauze. This was removed in forty-
eight hours and was theu (juite sweet. No further bleeding
occurred, She r&llied well, and the temperature did not
rise to 100" until the fifth day, when it was brought down
by an enema. The ligatures which had been left long were
out to about throe incfaea on the third day, and c&mo away
one by one. She needed no etimulant or special treat-
ment, and was at the present time convalescent.
The growth was found on mioroecopical examiQation to
be a spindle-celled sarcoma, commencing probably in the
eonneotive tissue of the cervix.
141
FOUR CASES OF VAGINAL HYSTEBEOTOMY.
By C. J. CcLLiNQWORTH, M.D., F.R.C.P.,
OB8TtTBtO PHYfllCUM' TO, AHS XKCTVnBa OM OBniTXIC UIMOIKX AT,
IT. TBOMAfl'S BOaPtTAI:.
(Received Marcli lit, ISM.)
{Abstract.)
Four cuscb of botu.1 t-xtirpatiou oi llic uh*rui per vaginam Arc
related, two of coIuniaar-v^'Ued varciuuina of the cervix, and
two of sqiiAEiiDUS'CeUed carcinomti of the porlio va^itiAlis. In
three of the oases the jtatients rocoYcred fitun the operation ;
one showed recurrence in eight mouths. ITie disease had ex-
tended into the bod; of the uterus in both the caioa of cerTical
carvinoinu. and the author eipreases a doubt wL4<th«r t\ut tta-
Bues above the iutenial os are respected as frequeutl; )ut is
Museum specimonfi arc ebowQ where the corpus uteri
baa beeu more or less invaded.
In the fatal case the patient had u parOTarian cjBt, situated
beliiud the uterus; this was removed hy abdominal Koctiou ou
the same dajr that the ragbal hyaterL-ctoiuy nau performed.
Death occurred ou the third day, apparently from iutestiool
paralysis ■
The paper ooncludeB witli some reinarks on the diminiuhed
mortality of the opeiatiun as compared with what it was when
Dr. W. Duaeau's paper was read in 1885.
Cask 1. — Mary K — , aged 46, waa admittod iuto St.
ThoniaB'8 Hoepital Jaimaiy 7t]i, 1889, ou accouut of
im^lar uterine hfemorrbage, which had tieen guing on
since October, 1888, aceom|»iDied with loas of Beah and
pajn in the left iliao region and over the sacrum.
142
VAOIN&L HTSTDKECTOHr.
Tfae pationt was married &t tlie age of twenty-one, and
baa had thirteen children at term and five premature
births, one at three months and a half, the others at from
fonr to five months. The last cliikl was horn in October,
1886. On that occasion the patient bad post^partum
hjemorrhage* For the last four years menBtraation has
been profuse- There baa been uo purulent or offensive
discharge. The blood lost during the past three months
baa been of varying quantity and of a bright red colour,
the discharge never ceasing entirely.
The nterns was normally anteflexeJ and freely
inoTeable. Body slightly enlarged ; cervix niiich enlarged
and indurated ; os fissured. Length of uterine canal
three inches. No thickening of broad ligaments de-
tected.
On February 5th, the haemorrhage having continued
more or less in spite of the rest, the patient was carefully
oxamined under etiier. On the posterior tip of tbo
oervii a BUBpicious-looking, irregular, dusky-red patch was
seen, raised slightly above the eurrouudiug enrface. It
was about an inch in its longer diameter and half an inch
in its shorter^ and extended up into the cervical canal.
There whb a similar but smaller patch on the anterior lip.
The diseased surfaces bled on the slightest touch. The
cervix generally was indurated. A omati portion of the
diseased posterior Up was removed for microscopical
exam i nation.
On February Ttb, Mr. Sbattock reported that the
epecimen proved, under the microscope, to be typical
glandular carcinoma.
The question of removal of the entire uterus was there-
fore considered and fully explained to the patient. The
patient herself was willing to have the operation performed,
but as her husband would not give bis consent, she left
the hnspital on February 16tb.
On March 4th she was readmitted for operation, her
husband having now consented that it should be done.
The operation of total extirpaCiou through the vagina
TAOIHAL HTSTBKKCTOMT.
143
was accordingly performed on March 8tb, ether bein^
adminiBtered by Mr. White. The Taginul orifice was
large, the vaginn itself roomy, and ita walU lax. The
uterus was normally anteflesed and freely moveable, but
the projection of the cervix into the vagina was esceed-
ingly slight, not exceeding a fraction of an inch. The
anterior lip was seized and drawn down, and the mncoaB
membmae in front divided. This was qo eooner done
than the tisanes of the cervix gave way and the volsella
lost itB hold. The Beparation of the bladder was aceom-
pKshed with a good deal of difl3culty. The posterior in-
cision was then made just above the posterior lip, and,
two fingers being placed meantime in the rectum, the
uterus was separated by the Bnger from its poaterior
attacbmeDts. The peritonenm came into view and was
incised with the point of a scalpel, the opening being
afterwards eolarged by means of the fingers. The ante*
rior and posterior incisions were now connected by lateral
iociaioDs through the mucous membrane of the vagina, and
the vesico- uterine fold of peritoneum was divided. (An
attempt to pass two fingers, from beliind, over the fundus,
to serve as a guide in dividing the peritoneum in frouC,
was frustrated by the fingers becoming entangled in a
ma»e of loose tissue. This afterwards proved to be
omentuui adherent to the fundus uteri.) The bladder
was DOW once more carefully explored with the bladdur-
iOund and found to be uninjored. The base of the broad
ligament on each side was then exposed by digSit^cting off
the vaginal mucous membrane, and a stout silk ligature
was passed completely through the upper part of the
oervix, from before backwards, in the middle line, to
enable the uterus to he drawn down. Passing a finger
behind the ba.'^e of the left broad ligoment and the thumb
iu front of it, an aneurysm needle was passed through the
lower part of the broad ligament, at a short distance from
the side of the uterus, and threaded with a double silk
ligature. The ligature was divided so that two ligatures
passed through the same opening. Half a knot was made
VAGIHAL HYKTEhEOrOUr.
on one and tlie enda held tiglit, vhile a fnll knot was tied
OD the other. Tlie fir&t knot wqb then completed, and
the utei'QB separated with scissors from its lateral con>
nections and divided np to the level of the ligatare.
8imilar ligatures were applied to the middle section, and
fiuBilly the upper border of tLe broad ligament was
hooked down by the finger, bUd the nppermost cectiou of
the broad ligameot, inclnding the Fallopian tube, was
ligatured. By dividing the tisBues as close to the uterus
SB poBsible, with scisaors, th« uterus was set entirely
free on that side. No hsemorrhage took place from the
broad ligameut. The body of the nterus was now seized
and pulled down sideways so as to enable the right broad
ligament to be brought into view and tied from above
downwards. A band of the great omentum, adherent to
the fundus uteri, was tied and divided, and the omentum
pushed up into the abdomen. When this had been done
and the right broad ligament divided, the uterus was frco
and was removed. The tubes and ovaries wore examined,
found healthy, and left. The omentum now prolapsed.
Again and agaiu, after being pushed up, it came down.
It was therefore held up while the vagina was packed
with two long strips of iodoform gauze, the packing
reaching for a little distance within the peritoneal cavity.
The ligatures on the broad ligament were left long, a piece
of india-rubber tubing being elipped over each bundle
outside the rulvs. No attempt was made to bring to-
gether the edges of either the vaginal or peritoneal wound.
Verj" little blood was lost during the operation, which
lasted two hoars and a quarter. Pads of wool, squeezed
out of a solution of corrosive sublimate, I in 1000, were
nsed instead of sponges. No douching was employed
either during or after the operation. A wood-wool pad
was applied externally. There were no symptoms of
shook during the operation.
For the first day or two the patient was sick at intervals,
and in spite of a small dose of morphia subcutaneously
she slept badly the night after the opcraliou. The cathc-
VAOINAL EySlEBEOTOHY.
145
tor was pBBBed every six houTB. Temperstiireon the 9th,
98-8° to 100-8° ; on the lOth, 996^ to 101°.
The iodoform gauze was removed for the Grat titae
on the niorniDg of the 11th, eixtj-six hoara after the
operfttion ; it was eatumted with blood und blood-stained
serom, but qaito free from disagreeable odour.
It was replaced b; a eiagle strip, wKicli was not carried
beyond the Taginal wound, but simply packed loosely in
the vagina, The india-rubber sheaths were removed
from the ligaturoa, which were now simply tied in two
bundles. It was thought the india-rubber tubing might
harbour dischargee and interfere with the drainage-action
of the ligatures. The change of dresBing was followed
by an attack of vomiting, and by acnte pain, which passed
off, however, in the courae of an hour or two. Later in
the day the patient paaaod urine voluntarily for the first
time since the operation. Temperature oa the 11th varied
from 99" to 102°.
Next day (March 12th) the patient was very comfort-
able and quito free from pain. Temp. 99° to lOO'*. No
sickness.
15th. — Discharge purulent and offensive. Gauze
tampon diBcontinuod. Bowels have acted slightly. No
pain. Not much desire for food. Ordered a fowl for
dinner.
profuse and blood-stained.
Tempoiature, 13tli to 17th,
17th. — Discbarge more
Patient quite comfortable,
varied from 98-4" to lOO'-t".
21&t (fourteenth day from operation). — All the liga-
tures on the left side, and all except two on the right, boing
loose, were removed; a small portion of sloughing tieene
came away with the ligatures on tho left side. The
removal was nearly painless. Patient complains of a
pricking pain during mioturition, but is otherwise very
comfortable.
24th. — The two remaining ligatures have not yet become
loose ; traction on them causes coneidei-able pain, Tho
central part of tho Taginal wound has united; at each
146
VAQINAL HY8TEBE0TOMT.
angle there is a small apertnrej not large enough to
admit the tip of the finger. Temperature, 18th to 24th,
98-2° to 99-8°.
From this date tie temperature was normal. The
patient left her bed on the SOth, and on April 15th she
was sent to the ConvuloBCont Home at Eastboome. One
of the remaiaing ligatures was atill firml; held, the other
bad come away on April 9tb.
She presented herself at the hospital od her return from
Eastbourne, looking very well. The opening at the loft
angle of the wound had not yet become entirely closed,
and there was a little purulent discharge quite free from
odour.
For 811 months after the operation the patient gained
flesh ; after that she began to lose ground.
At the beginning of November (eight months after the
operation) there was noticed for the first time a small
bud of Boft growth at the left angle of the wound, which
bad never entirely healed. Ther« had been no hsemor-
rhage-
On December I4th the growth had increased to tho size
of a hazel-nut, and patient complained of a little pain ou
the left aide of the peMa aind some irritability of bladder.
The discharge had been slightly blood-stained for the
past three days.
February 8th, 1890. — Growth not perceptibly increased
in fliKO. No heemorrhage since last note. Very slight
watery discharge, without ill odour. Frequency of mictu-
rition continues, and there is pain before and after reliev-
ing the bladder. There is continuous pain deep in the
pelvis on the left side.
The litems was handed over to Mr. Shattoek immedi-
ately after its removal. A large portion of the cervix
had, owing to its friability, been broken away during the
operation, so that the apeciuien consisted of the body and
adjoining portion of the cervix. It was at once placed in
hardening fluid, with a view to careful microscopical
examination. The following is Mr. Shattock'e report : —
VAOINAt HY8TEKECT0MT.
147
" The specimen shows that the morbici growth extenils
one centimetre (f in.) into the siibtitance of the posterior
w&U of the uterus, above the level of the iatemal ob. The
lower sarfaoe of the parts remoTed is exceedingly irregu-
lar, owing to the bre&ting Bwny of the greater part of the
diseased cervix at the operation. In front, the growth
infiltrates the entire thioknesa of muscnlar tissue, but the
peritoueam is eeparable and aninvotved. The same ia
true of the posterior wall. Tlie section made at the opera-
tion through Hie broad ligament shows no extension of
the growth in the divided surface. The connective tissae
at the aide of the cervix huB, however, undergone infiltra-
tion.
" The length of the cavity of the corpne uteri ia an incli
and a half.
" Hintolf>gy,-~-Hectlon shows branching colomns of ppi-
tbeliam invading the muscalar tiRsme. The colniuus have
no lumen, and are composed of closely packed cells, having
oval nuclei arraogcd vertically to the sabjacent surface
(columnar-celled carcinoma)."
I defer my remarks on this case until the latter part of
the paper.
Caii 2. — Emma F — , aged 35, married, was admitted
into St. Thomas's Hospital April 23rd, 1889, suffering from
a cystic tumour of the right broad ligament and ulcerating
oajvinoma of the vaginal portion of the cervix uteri.
The patient had been married thirteen years, and had
not been pregnant. Always had good health and men-
struated regularly until sixteen weeks before HdmisKiun,
when a hiemorrhage commenced which had contiuned ever
since. For the last month there had beeuan offensive dis>
charge, loss of appetite, and some loss of flesh.
Patient was a, strongly huilt, hottlthy-looking woman.
The anterior lip of the cervix uteri preeented an uneven,
graonlar, easily bleeding and flattened-ont surface of ulce-
ration, with hard, everted edges. Behind the posterior Up
there was a deep groove of ulceration running from gide
TAQIMAl HTSreBRCTOUY.
to side, dividing it, as it were, into two irregaJar flaps-
Tbe Qteras was freely moveable, and no infiltration could
be detected around it. The disease had not extended on
to the vaginal wall anteriorly and not farther than the
vaginal reflection posteriorly. Behind the uteros, and
springing from the right side, was a amooth cystic tumour,
occopying the liollow of the ssicram.
The organs of the chest were healthy. The urine con-
tained albumen [about -jV) J ^P- gr. 1014.
On April 25tL &bdomiDal section was performed, and a
cyst of the broad ligament, measuring 5 in. by o^ in., wae
removed unopened, after tying the pedicle with a single
ligature. The con tents were clear serum. The right
ovary lay close to the tumour, and the right tube, much
elongated, ran along its wall, the fimbriated end being
free. The wound was closed and dressed, the operation
lasting haliF an hour.
The patient was then placed in the lithotomy poaition,
and the whole cervis being seized with a volsella, the
entire uterus was removed per vaginaw,, the steps of the
operation being the same as in the preceding case. Very
little blood was lost. No sutures were inserted either in
the peritoneum or vagina. The ends of the ligatures were
left long, and the vagina was tamponed with iodoform
gauze. A gauze bag of sublimate wood-wool was placed
over the vulva. The operation occupied exactly an hour
and a half.
The temporary dressiog of the abdominal wound was
now removed and the usual dressings applied, namely a
bug of wood-wool next to the wound, and over this a large
thick layer of cotton-wool, the whole being secured by a
many-tailed flannel bandage.
The patient passed a fair night. At 6 B.m. next day
she vomited for the first time. In the afternoon she com-
plained of a patu in the right hypochondriac region, and
her countenance assumed an anxious expression. The
pulse became rapid and respiration hurried; the abdomen
became somewhtit dintcndcd, and vomiting supervened;
VAQIllAL HYSTEGECTOHX.
149
On cxftmiiLiTi.g tho cheat, the only abnormal sound. det«cted
was a double bruib intei-ual bo and on a level with the
nipple. It was doubtful wliether this was exocaidLal or
endocardial.
27ih. — Waa sick at intervals through the night and at
5j and was much collapsed. At morning risit, patient
looked a little better. The abdomen was slightly dis*
tooded. The mouth was dry and thiret was complained
of. The discharge from the vagina since the operatioii
had been chiefly Berum— ronly slightly blood-stained. The
tampon was easily remored this morning, and no further
internal dressing was applied.
In the afternoon the patient vomited about 12 Said ounces
of black fluid. The abdomen became more distended and
the pulse more rapid and feeble.
Being unable to account for my patient's alarming con-
dition, and revolving in my mind every possible cause, it
suddenly occurred to me that I had omitted to ask for tho
opongoa to bo counted before clo&ing the abdominal wound.
The nurse, on being appealed to, assured me that the
number was correct, but, in order to set the matter at rest,
my excellent resident officer, Mr. B. C Stabbj had the stock
of sponges counted. One of tho number was found to ho
missing. Immediately on being informed of this I pro-
oooded to reopen the abdomen. With some difficulty
tho missing sponge was discovered, completely enveloped
in omentum. The sponge had no ill odour, and there wore
QO signs of peritonitis beyond that usually found in the
immediate neighbourhood of the wound. The patient
Beomod no worse for the manipulations, bat the vomiting
and distension continued, and she died at 5 a.m. on the
28th, sixty-one hours after the operation.
The following is the record of the temperature, &c.
Temp.
Pnlw.
VLetp.
l!6th, 6 p.iii.
.1 1
86-4*
US
...
34
8 II.RI.
...
100-4
116
...
28
Mdn.
...
09-4
lis
...
26
26tli. i •.m.
-' .
d6-2
114
..«
t*
IftO
TiuOIHAl BfSTKUBCTOHT.
Temp.
?iil»
tt-p.
S a.m.
9S-8
104
21
Noon
100-0
116
£4
'Sp.ai.
100-4
134
30
S p.m.
100-9
1S4
30
Uda.
99-0
134
as
27th, 8.80 n.ni.
SOfl
140
40
& ■.m.
100-a
160
40
Sa.iii>
100-8
ItJO
32
Nooii
100-tt
160
m
■l p.m.
lOD-8
170
40
d p.m.
100-0
180
42
Autopsy (at 2 p.m. on th& 29th). — On opening the abdo-
men there was seen to he great distenaion of the stomach
and of the whole intestinal tract from duodennm to rectam.
The liver was pnshed up. There wag no peritonltia, ex-
cept as ehown by adhesioua in the neighbourhood of the
wound in the abdomina! wall and of the omentum to it-
aelf. There was no twist or kink, or other apparent
mechanical obstruction of the bowel. The wound in the
vaginal roof waa closed, so that no coromumcation exieted
between the vaginal citQal and the peritonea,! cavity, except
through the ligatures, which were surrounded by adhe-
sions at their attachments to the broad ligament. There
was a very little blood-ataiued Quid in the pelvia. There
waa no sign of hiumorrhaga beyond a little infiltration of
the connective tisaue in the stump of the uppermost sec
tion of the left broad lignmeat. The bladder and nretera
were carefully examined and found uninjured. A large
and hard lymphatic gland was found beneath the perito*
neum, on the lateral wall of the pelvis on each aide, imme-
diately below the pelvic brim. The left ovary and Fallo-
pian tube Were normal, ■"
The lungB were compressed and congested, 1}at other-
wise healthy. The heart was normal, except for a patch
of the sine of a shilling, of recent lymph, on the anterior
aspect of the visceral pericardium, and some staining of
the endocardium of the left ventricle. There were patches
of atheroma on the aorta.
The other organs were healthy.
VAOIHAL BTBTEKECTOUT,
151
Bffport on the Specimen. — Mr. Shattook received tlie
uterus immediately after its removal, and haa kindly far-
nished me with the following repoTt of the result of his
examination :^" The portio vaginalis is roughened on its
onter aspect from the euperficial ulceratiou of a csrciao-
matons growth, shown by tlie microscope to be of the
aqaamoaB-celled vai-iety. The aatorior lip is oonsiderably
enlarged liy the liiseaee, which has infiltrated also the ad-
joining portion of the vagina. On the poaterior aspect
the vaginal portion of the growth is deeply ulcerated, the
edges of the ulcer l^eing in<ratod and thickened. Ths
disease does cot involve the body of the aterus. In the
section of the anterior wall of the cervix the new growth
nowhere extends upwards for more than half an inch.
The divided edge of the vagina and the peritoneum on the
posterior surface are uninrolved.
*' Length of the entire uterine cavity two and a hall
inohee.
"Histology. — In vertical eectioa it ia shown that there
are braoohing columas of Sat-celled epithelium invading
the muscular tissue, accompanied with abundant amatl-
celled infiltration. The ulcerated surface is formed by the
breaking-down of the growth. There are many leuco-
cytes amongfit the epiihelial cells of the ingrowin^f
oolQmDS.*'
Hemarkt. — In this case it seems necessary to explain
why the two operations of removal of the parovarian cyst
and removal of the uterus were aodertakon on the same
day. The reason was this: the position of the cyatio
tumour behind the uterus made it desirable that it should
be removed before undertaking the operation oa the uterus..
To have performed abdominal section and allowed the
patient to recover before dealing with the uterine canoer
would have involved a delay of at least two or three weeks.
There boiug already ulceration of the diseased partx, such
a delay seemed exceedingly undeKirable. Hence, as the
oystio tumour appeared to be of a simple character and
non-adherent, and as the operation for its removal was.
153
.TAQIMAL HTSTIBBaTOKT.
tliereforo, likely to be capable of being performed rapidly^
I decided to do both operations at once. Tbe first opera-
tion occupied only half an hour, the geoond an hour and a
half. The nterua was very moveable and easily pullod
down, and the operation was accomplished without diffi-
culty. The operation of complete extirpation was chosen
in preference to partial removal, becanae I had no means
of knowing how high the disease extended. The speci-
men shows that the case was one for which the minor
operation would probably have been aafficient. It is easy
■to be wise after the event.
The canae oE death appeared to be intestinal pai-alyaisj
ft condition after abdominal section to which Mr. Malcolm
hai specially directed attention.* The autopsy showed that
there was no mechanical obstruction. I regret that I did
not pass the rectal tube, which might have had the effect
of relieving the distension. The lymphatic glands in the
pelvis were already infected, so that under any circnm*
Btances the patient would have had a recurrence. I am
disposed to doubt whether it is ever wise to operate when
tbe nlcerative procesa has commenced. In this ca.sQ I was
tempted, by the excellent state of the patient's health and
the shorcneee of the period since tho iirat symptoms of tbe
di5ea«o made their appearance, to give her snch chance of
relief as operation would afford.
Of the sponge episode I am heartily ashamed. The
blame rests with myself, and it ia no palliation of tbe
oversight to say that It is the first time such an accident
Las occurred to me, or that I ainned in good corapany.t
I see DO reason, however, to think that the sponge did
any barm, or in B.Dy way contributed to bring about the
fatal resnlt.
Ca8B 3.— Amy 8—, aged 43, married, was admitted
into St. Thomas's Hospital January Ilth, 1890. Married
" "Tho CoDdition And Managvment of Che ItiMtJnc kfter Abdouina)
SoctioB," ' Jlcd.-Chir. 'Xniu.,' vol. Ixxi, 1898, p. 13.
t Sea WiUon <H. P. C), "Foreign Bodiea left la ihB Abdomen atut
l/f^pmicioaiy," ' Amor, fljnwcolofpi^l TmnMctirm*/ vol. ix, 18W.
VAGINAL BTSTKRECTOMT.
153
at twenty-one ; two children, otie two yeara nvd one
seven years after marriage. Menstruation regular np to
five months ago, when the flow inerensed in quantity,
duration, and frequency. Latterly, the hiemorrhage hsB
been almost constant. Four days hofore adtnission had
a flooding on rising from bed in the morning ; the hremor-
rliage recurred the next day. Had eevere eliooting pain
at beginning of itinfas ; none the laiit few woeka. Dis-
charge watery, not offensive.
Patient a thin, Balh>w, ann-mio woman. Vagina con-
tracted ; oauteri high up, lips tliickened and everted, the
whole of their visible surface covered with a soft, eaaily-
bleeding proliferating growth, extending laterally for a
tihort distance on the vaginal wall on both sides. On the
right Hide and posteriorly, the edge of the posterior lip
VHH difficult to reach, being flattened out and fixed to the
vaginal roof.
On January 22nd, under ether, the body of the nierns
was felt fairly moveable ; cervix lixed. The organ could
not be depressed by proRsnro fiTiin (ibove. The contraction
made it difficult to ascertain the condition of the broad
bgamenb)*, but no swelling or induration was discovered.
The examination, as on pitvious occasions, gave rise to a
goo<1 deal of bleeding. A. small portion of the diseased
tissue was removed for microscopical ezatni[)ntion.
Od the 28th Mr. Shattock reported that tho growth
was a gqu«moutf-ci.i|lod carcinoma.
Oi^oration [February 6ih). — (The original intention wag
to perform supra-vaginid amputation of the cervix, but this
was abandoned ia favour of total esllrpatiun aa tb» opera-
tion proceeded.)
An attempt wan made to hold tho uterus iitcmly by
ineans of hooka high up within the canal, but unsacceas-
fully. Tho anterior lip was thoreforo eeixcd with a
voUolla ; but though traction was combined with pressure
from above, the drawing down amounted to little more
than overcoming the eversion. An incinion waa made in
the vaginal mucous membmnc beyond tho diwaijed Kurface
VOL. XlXll. It
ISi
TAG I HAL HY8-rEKKCT0HY.
and the bladder separated. A similar incision was made
poslerioriy atter seiziog the fHisterior lip, and Uoaglas's
poach opened. A ittout silk ligature was now passed
through the upper part of the cervix, and a further attempt
moilD to draw down the ntenia, hut without success. The
Ittft broad ligamunt was with much difficulty ligatured in
ill Kccliuns, and the lateral attacliments divided. A etniug
ilircad was nov passed through the body of the uterus and
traction made, but the organ would not more. The cel-
lular tissue at the basd of the right broad ligameut waa
therefore secured with a ligature ; but ia dividing the
cervix from it, part of the diseased portiou was unavoid-
ably left in tlio Biump. Still, the uterus could not be
morod. The hand w&b therefore passed into the peri'
toncal cavity and u nuinber of peritoneal adhesions of the
right tube, ovary, nod broad ligament gently separated.
This eet the uterux free; the ligature and eepsration oE
the right broad ligament were completed, and the uterus
removed.
1*he operation laBted no lees than three hours and forty
minutes. During the last hour the patient had been in
an alarming condition. The vagiua was tamponed with
iodofonn gauze, and wood-wool pads were placed over the
Tulva.
lu a few hours the patient rallied, and in twenty-four
hours she wna able to pass urine voluntarily. Aftor
forty-eight hours the temperature rose, and the tampon
was therefore removed. It was found to be highly offcn-
Bivo. The tampon was not renewed. Next day, the
temperature waa under 100°, and the general conditiou was
Batlafactory. Two ligatures came away from the left broad
ligameut on the twelfth day aod two more from^ the same
side on tho Ihirtt'cuth. On the latter day, a piece of
loose dead tissue also camo awny.
The patient left tho hospital on the 15th of March.
She had at that time a slight purulent discharge, and the
ligatured ou the right side had not yet separated j but her
genenirl couditiou was excelleut, and the wound had. con-
TJlQIHiL BYSTKHECTOMT.
155
h'acte^ tn verjr smnll dtmensiaQ9 and presented a liealthy
Bppearii iice.
Description of Parts removftd, — On the left side the
uterus lias Ij&en lemoved «t its junch'nii with the hroad
ligament, but on the right side a portiou of the cervix
18 missing. Nearly tbo whole of the cerrix is invulved
in the disease, the infiltration rea«hin^ Hhaost to the ob
internnm, but not beyond it. The disease has spread
into the connective tisiiue at the bane of eairh broad liga-
ment. A 8nb peritoneal tihrciid about the size of a walnut
is sttached posteriorly to tho lelt corner of the fundus.
Bemarke. — The difficulty of the operation in this case
vtiB due piirtly to the fact of the disease having extended
more deeply than was suspected into the connective
tisHne at the b&se of the ri^ht broad ligBment, but ittill
more to the extensile adhfaiima in the neighbourhood of
the right hrond ligament, the result of old pelvic peri-
tonitis. Tlie fact is that, slthongh the case has done
well, it was iinsiiit'nble for operntinn. I had not attached
eutticient imporlance to the immobility of the cervix.
Every obbo, utipccially in a man*a early experience, teaches
eomo vslaubic lesson.
Cask 4. — Emily S — , aged 47, married, was admitted into
St. Thomas's Hospital February 4th,^ 1890.
Family hi.ttory good, except that mother id said to have
died from cancer of the leg. Catamenia commenced at
the age of eighteen, aod, aftFer crai^ing for a year, continued
reguhirly and pninlei^sly. Flow scanty. Murric-d ut
tweQty-«ight ; nine children, the last six yeant ago ; hna
not menstruated aince. Patient has recovered wull from
her confinements, and has had no senons illness.
She first presented herself on Oct. 12th, t8t^9, aa an
ont-patient. She then stated that for the past mouth abe
had noticed a slight yellow vaginal discharge, which was
occasionally offensive. There was no paiu complained of,
and no heemurrhage except after coitus. A suitpicinns
roughnctis was at that titno detected within the cervix ;
15C
r&OISAL STiTBBBCTOUr.
110 unlieallhy nppoaraTico oiitsido tlio borders of the oa.
Tho condition iiTnlorwent nonppn.ront change until January
15th, 1890, wbon tho putient wah seisiod with severo pniu
ill tlio luwer purt of lliP fl.b(lomen,clLii>fly in tho rijijlit iliftc
fo!)R3 ; t1u< Hcl uf dl^ft^l:Hl<i^1U cauxt'd intense pniii.
On udiiiissioii, February 4fch, tlie pbtieiit was a welt-
nonrished, healthy'lookiiig woman. On binianaal examina-
tion, the uterus was found to be slightly enlarged, retro-
flexed and adherent. Cervix obliterated ; os patulous,
inner raorf!;iii rough and uneven. An ill-defined, tendtr
swelling felt on each side of the utoniB. Through tbe
speculum, the lower end of the cer¥t(ml ca,nal had a dneky-
red uneven appe&rance, and fcetid pus was seen i^suinf^
from the oa.
A fortnight later the lateral swellings had greatly dimi-
isbed, and the outline «f the body of the uterus had be-
come much more distinct iia felt per rtsctum. It was stiti
reti'oQexed and immoveable. A. carette was passed into
the cervix, with a view to remove a portion of the growth
for micToaoopicnl examinnlion. Several pieces (one of the
. size of a targe pen), which must all have b^en already de-
tjiched or nearly ao, were easily withdrawn, whereupon a
quantity of thicV offensive pus flowed out of the cervix in
a stream. A rise of temperatnro (102"6''), accompanied with
miiiaea and headache, which had occurred two days pre-
viously, was thus uccoutited for.
The fragineiits removed were handed to Mr. Shattock,
who, on Febniavy 2!!nd, reported that the microscopical
appearances were those of a coliimniir-celled carcinoma.
Extirpation was thereforo proposed and acceded to.
The operation was perroriiied on February 27lh, in the
manner previously dyscribed. Some difficulty was encoun-
tered from there being no projection of the cervix into
tho vagina, and from the dxHtion of the body by peritoneal
adheHioTts along the entire breadth of the fundus, These
adbesiona were separated by the fingers passed up posbe-
riovly. There being a good deal of oozing- from the lateral
aitflchmenis of the cervix^ the conneetive tissue at the base
I
VAOINAL UreTCRKCtOUY.
157
I
of each broaJ lignineut was ligatured. The broad li^montg
were then compressed by long platmuin<p1ated pressui-o
forceps, and, witliuut further ligatare (excopt one, passed
r\jund the uteriiiu end of Lbe Mt tultu and parts adjacent),
the detachment of thu utmus was proceeded with. Tiia
foroepa were left in aitu, To prereut the catch from
elippiiig-, thp handles of each were tied round with a liga-
ture. No taiupuii waa used; the ouly dreaaiag boing
wood-wool pads outside the vulva, kept iii poHitiun hy a
T-hnndage. Ko haemorrhage took place duriug or
after the detachment of the uteraEi.
The operatiou lastod two honrs and twenty nitDut«H.
The patient during the next two days had very little pain,
and scarcely any sickness. Tho forceps were removed in
forty-eight hours. Oo the fourth day, the patient was
nhic to dispense with the cutbotor ; and flatus was passed
per anuvi. An aperient was ordered, and the bowula acted
h-cely on the sixth day. Ou ihe eighth day, tho discharge
being very offensive, a vaginal douche of potassium per-
manganate waa ordered to be given twice a day. The
two lignturos came away easily ou the thirteenth day, each
with a slough attached. Patient very well and cheerful,
sitting up to tier mt-uls. Ou the seventeenth day avaginul
examination was made. Tho vaginal wound admitted two
fingers, and had a pcrf«et1y smooth bordor. The Bugors
p«ts&ed through it into a closed pou<.*h it bout two indies long.
The convalescence was oe frutt from pyrexia as a normal
puerperiniu.
Detcriytion of Parts removed. — The lower part of the
cervix has been destroyed by tho disease, so that its luwest
extremity has an irregular, ragged appearance. Ou the
right a portion has either crumbled away or been tarn off.
The di»ease has infiltrated up to and beyond the os in-
ternum. The mucous membrane of the body is blood-
stained and ulcerated in patches over its whole extent'.
Many of the ulcers have ragged borders, and from their
surface are 8(.>en euiall rounded projuctiuns, of the size of
a pin's head. Tho muscular tissue of tho body, except
VAOINAL HVSTKRECTOMT.
Dear tbe os iiitemnin, ilnes not appear to he hifiltiated
witli new growth; but it is (I'dt'tnatoua tbrougliuiit, aud
here Biid th&re are seen jellow alreaks biLving tbe appear-
ance of fat. The peritoneum along tlie wbule breadth of
the fundua posteriorly shows nunierouH ecchjiuoaes, ntid
slireda of adherent meoibrane. The titema has been re-
moved olo&ely np to the wall on both sides.
JI'ii<ioio(iicol rfj'ort hij Mr. Shathrk, — The disease ia
typical camaoDiQ, arising in the uterine glands. The
upper lituit of the disease carrespoTids to a line three
ceotimetres from tbe top of the uterine cavit^', and one
centimetre above the level of the os uteri internum. What
remaina of the glitndnlnr structures above tlii^ poiiit 18
normal, but most of the mucous membrane bus boeu de-
stroyed by ulceration, the epithelium having; entii^ly dis-
appeared, Willi the (greater pnrt of the glands, the deeper
extremities of which are the oulj portion remaining. A
considerable amount of extra%*a»4ated blood, of old date,
is seen in the remains of the mucous memhriine. There
is no iadicutioD of malig'uaut change in the diseased mu>
coua membrane of the body.
Bemarkn. — This was the first case in which I employed
clamp-forcepH, instead of ligatures, for securing the maioi
portion of the brond ligamenta. The rcault was entirely
satisfactory. The largov nnioimt of sloughing produced
seems to mo a diEtinut advantage in cases of cancer. It
was also the first time that I discarded the use of internal
dressings,
denrrul Remarks. — In bringing these cases before the
Society,Iam notnnmitidfulof thediHcnsHionlhatiutheearlj
port of the year 1H85 followed the reading of Dr. William
Duncan's abte communication on " Total KjLtirpation of tho
Uterus," orof the fact that, with twoexceptions (SirSpenoer
Wells and Dr. Graily Hewitt), every speaker whotook part
in that discussion agreed with Br. Duncan in condemning
the operation as unjustifiable. One of the chief grounds
for this wholesale condemnation was the high mortality o£
the operation. Dr. W. Dunca-u collected all the cases
VAOItTAL HVSTEKICTOHV.
159
lie conld find recorded up to that date, 276 in nuraTior,
and found the tntnl moi-talit; to he 28"0 per ceat. But
alt1ioug}i tlie effect of tliat di»cu»air>n was to checlt the
perforniarce of the operation in this country, so thdt
comparatively few cases have been publisiied Rince, the
gynrecotogiels of otlier countries hare been under do euoh
deterrent iiifluCBce. The cousoquence is, as we mij;rlit
expect, that the mnrtftlity has been already considerably
reduced. Keen nt th&t time Dr. W. Duncan's estimate
was probably too high. The true mortnliiy of an opera-
tion is not to be arrived at by including every case, Iiow-
erer inexperienced tlie operator, but by taking the reaulta
of the best operatora, and those of largest experience. In
Dr. William Duncuu'e list there are no fewer than thirty^
five operations by racii who^e experience was limited to a
single case. Marliu collected the reeults, up to the end
of lH86f of the six Gerroan operators who had the largest
exporiouco, and foimd their mortality to be lo'l per cent,
(31! cases, with 47 deaths). But even this has Kioeo
been greatly improveJ upon. In his reply, at the oiose
of the disL-usKioti to which I have just allnded. Dr. W.
Duncan expressed himself as feeling " sure that increased
eitperiencc would never bring the mortality down from
28 per cent, to that which follows supra- vaginal amputa-
tion, namely, 7j per cent." Huw do the Egures stand
DOW F At the Third Congress of the Germau Gyiioico-
logical Society, lieM nt Freiburg in June, 1889, Miiuch-
moycr reported that, in 160 cases oE total extirpAtion of
the oterus, performed at Dresden between the years
188S-89, the total mortality was 5'4 per cent. Forty-
eight of these ca«ea had already been reported by Letipold.
Of the last 112 operations, 52 were per/vTmed in guccetmion
without <i single death. In 80 oE the 100 cascN, the opera-
iioD WHS undurtaken for canocr ; only foar of the patients
died from the effects of the operation.*
la the same year (1889), Kaltenbach reports sixty-two
• ■ Arcliir for OynUologitv' B.l. t»xvi. ttea llofi, Bsrllii, 1889, pp. 4X4,
tl **q.i *-ai ' Cdntralliliktt f. OynSkol.,' Aug. Srd, ISSa
160
•TACIKAL BVSTKHICC'rOMT.
cases of total cxtirpa^tioB of tlie uterus, with two deaths ;
one from liubliinatc-poieoiiiiig in & puik'ut with pyelo-
nephritis of one kidney and. atropliy of the other ; the other
f rum injury of the ureler and proJjabiy also of the bladder.*
Turning to France, wo End that I'ean, in the yeara
1886-7, extirpated the uterus for cancer in tweuty-two
cases, with seven deaths; while of the sixteen operated upon
in the first eeven mouths of 1888 not one died.f What-
ever may be the ultimate verdict of the profession with
regard to thh operation, it is evident tLat the objection
on the ground of its heavy mortaiity must henceforth be
iibandoned. Taking' tho ctincer ea^us of the three opera-
tors whose statistics I have just tjuoted, the total mortality
is 7'3 per cent., and if the German statistics ulone be
considered, the mortality is only 428 per cent. If every
newly proposed operation that shows at first a high death-
i-ate is to be at once deuotincod as unjustitiable, thero is
nn end to surgical iruterprise and Burgical progiess. I do
not propose to enter at present into tho larger quostion as
to how far the operation is capable of diminishing suffer-
ing and prolou^ng life. The data lor prououucinga fiual
judgment on lliose points Hre not yet attainable. A cer-
tain time must elapse after an operation before we can
speat of its permanent reitulta.
If we take, as the test of 9ncce8« in operations for cancer,
freedom from recutrenco for a [leriod of three years, it
will be obvious that most of the cases included iu the
foregoing atatistios have been operated upon too recently
to allow of a statement of results. This is not the ease,
however, with regard to all of them. Thus, thirty-oao of
Leopold's cases at Dresden were operated upon more than
three years heforu the date of M iinchmeyor'e rt-purt.J OE
this number no fewer than »ovenlecu, or 04 percent., pre-
seutcd no sign of recurrence.
• 'ContrnlblaU (. Qyalkohgie,' Nuv. 2a<l. 1S8Q.
t Seclieyruii (L,), 'Traill d'ljjil^raUiutie t-t d'h^iU>rM!toiuii* ^u !>. voio
vt.Kiin-U,' P»ri., 1899, p. 649.
I ' Aicbiv fur Oyoaku logic.' Band xix. BetBu, 1887, p. 401.
I
VAQINAL HYBTICHECTOMT.
lai
If we agree with Dr. John Williams and uthers that it
is justifiable to consider a case cured it' lino years have
elapsed without a recorreucej the propoption of cares will
appear still more rcitinrkable, for, of forty-two cases
operated upon more than two years previously, 27, or 64*5
per cent., remaitied well.* These results cannot but ha
regarded as moat encouraging, and the record of the suc-
ceeding yeai-3 promises to be equally satisfactory.
There is one point in regard to the pathology o£ oerrioal
cancer as to which two of my cases (Noa. 1 and 4) appear
to mo to furnieh evidence of aome value. I refer to the
qnoation whether cancer of the cervix does or docs not
tend to spread upwards Into tho body of the utorna. In
both the cases just named {each of them being of the
columnar-celled variety), an examination of the specimens
and of the sections kindly prepared by Mr. Shattocfc will
show that the disease had distinctly invaded the body of
the uterus. It is maintained by the advocates of supra-
vaginal ampututioa of the cervix for cervical cancer that
the disease exhibits little or no tendency to invade tho
body of the ntenie, and that, mainly for this reason, total
extirpalioD poaseBses no advantages over the partial opera-
tion in the treatment of this affection.t The point ia
of great practical importance, and every case, capable of
shedding light upon it, ought to be recorded. It is true
that the minor operation may be extended so as to in-
clude the removal of a portion of the body of the uterus,
and Dr. John Williams, an nncomproniisiag eupporter of
this operation, even speaks of carrying the excavation of
tho body so far aa to leave a mere shell. But surely
this is to make the lesser operation as formidable and diffi-
cult if not actually as dangerouR aa the greater. More-
* rt may bo w^ll to ilnto (hat Wfurc thi-'X' fs|;iireH wi-iv publixhcil, orerjr
onpnf tlir pideiiU ua« roiuiDiinii'fttcd with rithiT dij'cotly or throagli (beiT
iDCdkHl nttciiilunt. Mont of tUuw pri'>ciitoil tlivnmulvci pnnnnaUjr tat ex-
•nDiiutitta j tlje tevr, (iifnts-Unl a incditul rvjwrt. In only uiic itiatauo* vrat
no aniwer roc«iveil to tht? Ictt«r of Inquiry.
t Willuiiu« (J.j, UltrvuiBD Lccturca on 'CanMT of th« Uurn*,' Loud.,
laoa. p. 116.
162
VAOINAr mr«TEBBCT01IT.
over, this extensive bollowing out of the body of the otorne
is not ordinarily practised in supra-vaginal amputation of
the cervix, and does not form a recognised part of the
operation. Indeed, it is difficult to see wty it has been
Buggested, if it be true that cancerous disease of the cervix
has no tendency to grow towards the body. If, on the
other hsriid, fnTtherobeervatioQ shoald show that early ex-
tension of the disease upwards into the liuily is an event
of not ancommon occurrence, ataay rare iu cases of oolum-
nar-oelled carcinoma, it will scarcely be mnintaincd that
supra-vaginal amputation of the cervix ia as thorough and
satisfactory a mode of removal as total extirpation.
"With regard to the alleged early implication of the para-
metric connective tissue, I may point out that this haB
recently been called in question.* I do not, however,
propose to go into this matter, because it does not really
affect the question as to the relative advantages of the two
operationa. In neither the one nor the other are we able
to remove any considerable amonat of the Burrouiidiag
coDQective tissue, and any argiimont founded on the
special liability of this tissue to be invaded would tell
equally against both operations.
I am, of course, perfectly well aware that the evidence
afforded by two cases as to the early iinplicatiou of the
body of the uterus is far from being conclusive. Never-
theless, specioieDB of cancer of the cervix, in a compara-
tively early stage, and removed not in the post-mortem
room, bat from the living body, are sufficiently rare to
give even a single specimen a certain value. And the
fact of the dieeaae Laving spread into the body in both
my Bpecimena seema, at any rate, to afford prima fa^cie
ground forfnrther investigation. With regard to miiseum
specimens, they, for tlic most pnrt, illustrtito only thw later
stages of the disease. An exoeptton to this, apparently,
18 to be found iu the specimen from St. Bartholomew's
HoHpilal Museum, which forutt the subject uf an excellent
* SincltuT (W. J,), "Vaginal HjMurectoinj for Cancer," ' PnctiUuuur,'
»M., 1889.
TAGINJIL BYSTEOECTOMT.
]6d
iTtho^rapnic plate (Plate siii, iig. I) in Dr. Willlama's l>t»ok.
It is signiScant thtit iu tbnt sjiecimen also tbe dii^iense lias
Spread upwards into ihe body of the organ. In tlie later
stages it is certainly' the rule to find the Itody tuoit or
leas deeply iutpliciited. It is so in almost every one of
tlie specimens in tbe museiira o£ tlie Roynl College of
Surgeons, and it will b« aceu to be aoiD the specimens on
tbft table from the museam of St. Thomas's Hospital.*
Another point upon which the advocates of the pai'tiiil
operation Iny miieh stross is that when tlie disease recura
after high nmpiitation of the cervix, the recurrenco itsn-
ally takes place in the paramctnc coDnectiTe tissue and
not iu the uterine stump. I have no evideuce to offer on
this question. If furtherobservations should establish the
truth of this slatenient, it will of courKe tell so fur in favour
of the uiinvr operation. But tt will uot finally dispose of
the question. There are other points to be couaidered
(rui, for example, the possibility of ther« being separate
Doilulcs of ennceroiis growth high up in the boily), which,
however, it is beyond tlio scope of this paper tu discusH.
May I be permitted, before I conclude, to muke two
remarks? Tbe first is that, while hexitiiting, for the
reasons I hare given, to accept bohir of thocnnclumons at
which Dr. Williams has arrived in hia work on cancer of
the uterus, I yield to no one in my admiration of the
th(j roughness of the clinical and pathological obflervations
npon which that work is based, or in my gra.tituile for the
many valuable 1e>ssoiis I htivo leni*nt from it. Tho secoud
rpmnrk I wish to make is that, although I have endea-
voured in this paper to show thiit there are good reasons
for uot hastily dij^couraging tho treatiueiit of cervical
cancer by vaginal hy^tereclomy, I aui by no meaus ao
enamoured of tho operation oh not to bo ready to welcome
any other method of trcatiueut that promises a smaller
immediate mortality and bettor permuucnt results.
* For detailed doteriptioii or tbew •.pecimeni, tee ncrt pag*.
164
VAQIKAL UVSIKKBOIOMY.
AppShdij! descrif/ttve of the Museum Specimens fhown in
illuatration of Dr. CvlUngwQrth'a Paper.
Specimen 1 (St. Thomas's Hospital Museum, No.
0047). — The nteru3 and vagina witli part of the Wadder
and urethra. The cervix is destvoyed by cancerous ulcera-
tion, the vaginal portioa baviug entirely disappeared.
The vaginal wall is invaded by the ulcerutioa all round
the cervix. A zoue of similar ulceration in seen, separate
from the above, close to the surface ef the vagina and
reaching to within an eighth of aa inch of the meatus
uriuarius. In fi-ont, tLis zona is au inch in breadth ;
posteriorly, rather less. The two sites of malignant ulcera-
tion appear to be continuous along the eubmucouB tissueB
o£ the vagina, the surface of the inteiveiiiug mucous mem-
brane being fur the most part uunffected. The disease
has invaded the tie&ues around the lower part of the
vagina, a ring of infiltration involving the urethra, sides
of vMgina, and recto-vaginal septum. The disease ei-
teudu upw&rdti into the budy of tha uterus to within one-third
of an inch of the fund us, affecting the whole thickness of
the posterior waU with the mucous membrane. The same
i» Iruo of the anterior wall, only that the disease does not
roach quite so high. Thore ih no obvious exteusiciu of the
disQofie into the tiHaaes at tlio sides of the uturutt. The
cancer is oE the squamous-ceUed variety.
Sfjucimcii 2 (St. Tiiomus's Hospital Museum, No.
Q0<'i2). — The uterus, ovarioa, and bladder. The uterua is
¥ery much enlarged ; the cervix and lawer part of the hody
are intiltrated vritli malignant new growth, in some parts
ulcerated on the surface; Ua: upper part is nvtHarly affected,
though a sjnaii part of the mtmtular strvcture there appears
to hf. heuUhy. The cavity oi the body is considerably en-
larged by uiceratiou of the a^eeted mucous membrane and
muscular tis^iuo. The oonucctlvo tissue on all sides is
deeply involved. The growth in the anterior wall of the
cervix ha« extended to the bladder, EoroiiDg a prujcctiou
TAarSAI, RTHTKRKCTOMT.
165
into its cavity. The disease extt-nJs downwarfJs fo as to
involve a portion of the vnginaand contiguona porliona of
the left ureter, the bladder, and the iirethrft. The right
ovary is healthy ; the left, which ia closely adherpnt to the
litems, is the seat oF carcinomatons infiltration, by which
it 18 increased in sizolothatoE a largfe nntnge. A portion
of largo intestinci adJiores to it, but does not appear to havB
been invaded by the disonsu.
Under the microscope it. is now impossible to say
whether the growth is a sqnamoua or a cohitDDar*cell>ed
care in omit.
Specimen 3 (tit. Thomas's Hospital Museum, No. oq53),
— The uterus, vagina and bindtler. I'he cerri.^ and /oirer
part of the body of tke utenis are- ci?mpletely destroyed by
cancerous uk'eration, the growth involving tke mwenlar
tianne ahoiw ifie iileeration In wUhin an irtrh of thn findns.
The poalerior wall of the bladiler is involved, and a noni-
miinication exists between the bladder and vagina. There
ia no invasion of the broad ligament)! exrept the connec-
ti\-e tissue at their base immediately coutiguous to tke
cervix.
The disoMSo is shown tinder the microscope to ho
cohimnnr-eelled carcinoma.
Specimen 4 (St. Thomas's Hospital Museum, No. b<iS7).
— The uterus and bladder. Tlio whole of the cervix and
the low^r part of the body of the uterus aru ()e»ti'oye>d by
cancerous ulcenitiou, the new growth haviof^ extended
upwards I'ji/o the hxly of the utffru« lo within a quarter of an
inch of the fwidiut, and downwards into the upper part of
the vaginal wall. The tisauuH around the cervix, including
the ponterior wall of the bladder, are invaded. Tho
lower part of the right broad ligament is involved ; tho
left broad ligament is fr&e.
The carcinoma iu shown microscopically lo be of tho
equamous-celled variety.
Specimen .5 (St. Thomna's Hospital Museum, Nn. OO.50).
— The uterus and vagina, with the bla«ider and rectum.
The body of the uterus is a little enlarged, and the lower
im
TAaiKAL HYSTEKECTOHT.
part, Up to a point half an inch aboite tke o9 internum and
au inirh and a quarti^r b«low tho funduti, iu inHUrated with
cancerouB malter. The lower part of the cervix is
destroyed l>y ulceration. Tlie vagina, oxoept Mt its lower
part, is similarly destroyed, and in its pUice is a largs
ill-defined cavity, into which the bliidder, uterus, and
rectum open. The lower portion oE the nrethra remnins,
but is uricotinected with the bJadder, the lower part of
which 13 destroyed. The anus is entire ; the rectum opens
into the common cavity by two apertures, one, two inches
above the aiiti», tho olhor, five inchoB above.
The specimen is shown by the microscope to bs a
squamous- celled carciuotuHj with uests.
Dr. John Williams expr^Baed hie high appreciation of Dr.
Oullingwoirt.h'a papier. Tbe qiiesttun raised in it — the treat-
ment o( paropr of the (inrvis of the ut^ruB — was of vflry great
importiinct:. In coming to a conclusion upon it, rui:;iird nhould
Iw had to two tiiiuys ; (1) thi- direction of gruwth of <mticer
when it hf^au in the wrvis, luid (2) the difference in tin; rexulla
ohliiiuvd afti^r totu.1 extirpation i>f the uterus aad supra-vaj^inal
amputal ion uf tlie cervix. With regard to the direction of the
growth of cancer of the cervix, it had been maiDtalned that its
tendency v/oJi to aprood outwards towards the parametric tiesue,
If the disL-aae began near the external orifice, it apread upwards
and outwards; if it be^Hu near the inl^rnal orifice it spread
downwards pud outwards, so as in each oiso to involve the
whole of the cervix j but it showed no tendency to invado
thi- liody cif the uterns, and coiisetjuently invaded ttiis [lart only
in iidvanoed stiiges, when the paraiiit'lric tissue had been
affected. The- object of Dr. Cullinjfwortb'a pa[>er waa to ehow
that cancer of tho cervix invaded the l>odyat an e&rlier period than
that just statad, and that consequently total extirpation of the
uterus waa an operation preferable to supra-vagiual amputatioa
of the cervix in tfaia dijieaae. In eupport of this view he has exlii-
l>ited some half-a-doien spccinienBof the pelvic organs of women
who bad died of eancer of the cervix, and i>iveii records of four
cases, aecompimicd by specimens, in which he hud pitrfonued
total extirpation for cancer of the cervix. Now, whfLt did these
apecinienB show? The half dozen taken from the body after
death (and every hoapital museimi in London contained uny
numlM^r of aneh specimens) sb^iwed thia : that in (tach onu of
thuui tUu body of the uterus wa« left almost if nut quile in its
TAQIHAL BySTBUBCiOUY.
167
entirety, whil« the cervix had completely clisappoarod ; that, Ibc
coDitective tissue arouud Ihecorva, that id lb() bMe of tbc- broad
ligament and ihat aroimd llie U|jp«.T i^art of ibe vaK>i">- b'l-d Uxta
eatan &va.y: iliat tlieLbiidi*!' or the reitiimor h<Ah liiul bui-u in-
Tudcd: iLud that th« result- vf tlie disease bad bi?eu la form il Iitrgo
caTily in the ntrufture of tjie wrrvix and itM surroiindiugB, and to
k<avL' lln^ IkkIv of Mil' nteriiH jilinost in itx eutirvij. What
atroiifjer ovideiiw cuiilil [iiivi? luH.;!! Imiitfjlit forwiLi'd lo sbow tbat
the body vi tbv utcrua viae Dot a mors(.-l to tbu tital« o£ <.-uuo^-^ of
the feirix. and thB-t. aincL-ir of tlif ctTvii rcvelk-d in ibe |iiiraiue<
triuDi, but WHB diiiinclincd to invajle th« uIltiup body '^ But what
did the four caaes which formed tlie baaos of thi> pajier show?
Oae of tb^in was a case of squamoug epitbfliuma. Tije diHt-uj^e
in ibis iiistAQoe waH, as usual, <)uiti> supi^rticial . being only half
an inch in depth— but il bud sprt^iid beyond the cervix on to the
Tft^iinl wall. tliuH eliowing, as l]»d been before pointtiJ out, tbut
thedirectionuf growthof HquiiniO'iis^pitbt^ltoinaof the<.'irrvix wu8
snperficiiLl, Hud oii to uud ulon)^ the vu^iiDLl walls. Ttit<ra wnu
u» eusjjiciou that the dis'.uee bud inviidt;d the body ia this
cji«e, and yet the whole uierua was removed. In the other three
cases Ibe ei^rciic of ihe utj?ru8 was so eoRi|dctely diseaspd that it
WM found inipossild? tft t;rip the uterus during the oj^eration,
for by reason of ita friability it broke dowti bit by bit. IiJxauii-
DAtioQ of ihij or^an showed that tbt' whole thit^tceiiin^ nf the
««TTix was eunf^Tous, and that tho pnriinietrio tiaxuo had been in-
Taded. So that tbvitt- cases wcr« cxamplca of cancer in aii advanc'ed
Btag>>, in which no openition. and k-asl of all Buth a ikriong
operation a*) lotiil extirpation of the uturuw, was juatifiablo (iii
Myiiig this Pr. Williaine *])oke with the advantage of having
rsamined the orpins), for it gave the pntient not tbn faintest
chance of a radical cure, and an operation of such ntiignitndij as
total extirpation fibould never he uadertakeu as a palliative
meiiBure. But even iu these spi-cimeiiti of Eulvaiiced cancer bad
the disvaKi- irassed the inner orilici< and invaded the liody P T>r.
CuUiDgworth in bin paper stated thut the seelions under tho
ii)icn>BCO[>e showed that it had. Dr. WiUiania bad examined this
MVltonn and fonnd in them no evidence one way or the other.
Indeed, the seetiunn showed nothing except cuui^r in an organ
largvly compoHcd of niuscuhir-libn.' cells; luey showed ao struc-
ture charucteristic of the body or the t-ervix of the uterus. On
eiaminatioti of the or^ns theintielves he could find no evidence
that the disease had passed the inner orifice. Owing to th«
ulocmted state — which was admitted not to Ita cancutoua — of ono
of them, it was jierhaiw impossible to deeide this point, With
regard to the other, he could find no evidence that tbs diaeaao
hita imeuied beyond tho limits of the cervix in the direction of
the body, while it was clear that it bad in all theifecusfH invaded
the parametric tissue. The specimen exhibited by the Pivsideut
108
TAOINAT. nTaTKRBCTOMY.
bad cl«iHy passed tlic internal tirifico, but ia tlile case, apain.
canci^r waa iti an mlvmicad stopt?, for it liail iDViuied the cellular
tiflsiic a.romi(l the cervix and niii.de th* eaee (|niti> unfit f nr opera-
tive mpUiSurt^s. l>r. Homiau's siifcimm IwlonseJ to n clasa
whioh bafl been desprilwd by Dr. Wlliams from its earliest to
itB latest stwffes. and wns in that stage in wbicli opemtive pro-
oeedinei* did imttjiiifc but harni. 3i) tb&t «very one of the apeci-
BlMlfl esLibitjrd to-tii^ht vfnt tAt pri>ve tliiit cancer of tbe cervix
showed a tpndi>Ticy to j{row nnlwarda t^wai-ds the parametrium.
ftiid invuded tbo bo<ly in the later s^-ngeg only. The result* ob-
tiiined nfter tobil extirpation and supru^vaginal umputaltun of
th« cervix went to show the same thing. After aupm-Tf^inal
amputation recurrencre took place, not in the atumpuf the uterus
left, biit in l,lie celliikr tin8ue around (tlip except ioiiB to this wcro
rare); and after total eitirpatioo it orciirreil of course in tlie samo
place, and. if stat.istieaof rhe aame period bo taken, far more fre-
quently. Thid may possibly be explained by the fact that total
extirpation was at one time perfurm^ed under a false impresniou
of tbe patholopy of cancer, for tho more severe, wbile 8i)pra*
TftfipnR.! Hinpntation was adopted in leaa severe cosea It smmed
to Dr. Williams that if the recurrence after supra-vaginal ampu-
tation tnok place in the cellular tissue and not in the nterins
Rtump, total extirpation presented no advantages over tbe lesa
Severe operation.
Dr. WnxiAM Dcncas did not Ihinlt that earwr of the cervix
uteri tended to spread up into tbo body of the utenia until (io
tbe great majority of cases) it bad previously iiifiltnited the cel-
hilar tissue outrtiile tbe ulerua. Ke waa qiiit^ of Dr. John
Williamn'a opinion that tbe many niuseuiit-^pei'irtienH nowabowii
cle.irly support**! this view, for althoncli tho spenimens wero
tb(ie« of cuDcer iu the latest staRc, the uterino body was in most
of tbecn apparently un>tffeL'ti>d. Since reading hia paper on total
extiipatiori of tbe iiteriis lM?Enre tho Soeiety in 1885, Dr. W,-
Dunoan bad carefully examined everv ca»e of uterine cancer tbat
lie bad met wilh. In only three could lie satiitfy himself tbat the
Iinraiuetric tissue waa unaffected and a radical oi>omtioii[ advis-
nble. Ho drew attention to the importAneo of carefully eiamin-
iug tbe utero-eurral lij^anients by digital exploration throu^b tbe
rej-ctum. for in many caaea of cancer in nliicb the ordinary hi-
inaniml examination showed the uterus to be mobile, yet either
one cr both utero-sacrat liKanients proved to b« thickened from
oruiceroiiB mfiltration. This thickening could only be det«c(ied
on TPctal eiamination. and of course, wlieuover found, absolutely
Bontra-indirat^'d operations. He asted if Dr. Cnllingwortb exa-
mined by tlio rectum iu bis cases, ub the fact that in some of
them till' Uterus could not be drawn down with a volsellu seemed,
in Dr. W. Duncan's opinion, to prove that tho cancer was not
liniited to the uterus at the time of operatiou. With re^rd (o
iVs
TAOmAL BTSIIBECTOHr.
169
tho conipnmtivp risbs of tnt&] extirpation hdJ sujirs-vagiiial am-
putatton, Dr. Duticon rt^rJcd foreign statiHlica as tim^ticarily
valui-lesa, inasmucb as tokl extirpation was performed f<>r ollior
conclitious thau cuncer, sUL'h iis prolapsus utyri. He B^i]] iiiHiii-
taiued tbat in tlie tew ciiscs wLero any mditaJ procedure was
cuIIimI fur, the siipni-vii^iiiiiL amputatiou was the prcfcraltlu
operation.
Dr. W. Jai'p SiNciAia referred to the fact tbat the minor
oprratiou bad been almost uaaniraouslj abatitIoiii.>rl hy Ocrmiiui
0[iera.tive gynscolc^ista us a point in favour of lulal cxtirpatiun.
A» tins operations wpiv performed almost (;nt.iri.'ly in the public
boKpituls, the Uiinnau reports must Ijc cunsidered fully aa rt'li-
bLIc aa any pulrliabeJ. He would confine hb remarks to the
question of the direftiou in which the diseano of the uterus
spread. It ^as admitted on all Lands that the rcisiilta of total
extirritttion for cancer of the body were comparatively favourable,
and it wan uNo a fact, though itnl perhaps »u frankly admittt'd,
tbat cKtirpatiou for cancer of the portio vaginalis gave also per-
manently Kood rcaults. The least favourable class of cases was
t(an<»^r of the cervix. The reason of the above facts neernod
ohvioiin. In t■■^nce^ of Ibis body and of the portio vnglnalia an
operation luailc a clean iiwcL-tJ of lill the affecti'd tiDstiu at a con*
Hideruble diHtuuco auatomiciilly, if not pbyMiohtyiical ly, from the
disousu. Oa the oilier Land, in cancer of the cervix it was ex-
Irumely JifBciilt, except in the very earliest caues, to keep wide
of the intilfrated tisancH. A^in, cancer originiitiuy in the cer-
vical eauat was liuhlo to remain ooncealed for a lurj^'ortime than
in tbe body, where it causod pain and dinehargo, or in the tip
of the vagmnl portion, where it produced atypfeal hirm«rrha(;&
It the cancer were to spread, it must do lo in the parauiulric
etractarcB, hut tho rule wan that the apreading ocenrrt'd com-
pBTatively late in the proceus of diHcase. Agi&iu, the exccpliima
in which the diaeaHO Mpread up and down to an extent which
could only bo aaeertaiued after opj.<ration wore so numeronii that
the only nafe rule was to perform the major oi)eratii>n as early
na poiiailik'. The openition was called major, hut the ttjieitker
doubted if it WOM d» dan^emns an flome Hurgical pr(KM:idureij wbiob
had l>oon propoBOd an coui]>arativcdy Hafe. These latter avoided
wounding the peritoneum, hut tlic-y left lUo eirciilatiun, both
batniiv and lyniphatie, comparatively uuiuterni]ited, and tbat
was asouroe of immcdiat*^ and remote daufji-r. Dr. Sinclair's
experience of tbe o[>emtion now iLuioiinle<l to eit^bteen cantn of
total extirpation for cancer, Twelve of tlieiie o]>erationH had
hwjn perfonned within tho last twelve months, and all were
olive Bud welh except one patient who died of ai.'utc seidie |x.Ti-
tonitiii. He gave dutaiU of cases of extirpation over two yearn
ago in which no reeurronee htul tuten place, and the patient re.
mained in very gooi! health. He conobide<i hy eiprcsam^ strong;
VOL. XUXll. 12
170 TAQIHAL HTSTEBECTOVT.
coQcarrence in Dr. CrtUingvorth'a opinion of tbe value of total
extiqmtion, and congratulated the author of the paper on the
conrageoue honesty of his statements of fact and opinion.
On the motion of Dr. Lbwbeb, Beconded by Dr. W. S. A.
QsariTB, the discussion was adjourned to May 7th.
MAY 7th, 1890.
GsAiLY Hewitt, M.D., Past President, Id the Chair.
Present 38 Fel]owB and 10 ViBitorB.
Books were presented by Sir Hy. W, Acland, Proi.
Allen, Dr. Calderini, the New York Aoademj of Medicinej
the Guy'a Hospital Staff, and the WestmioBtcr Hospital
Staff.
Charles Arthur Morris, M.A., M.B., B.C.Cantab.,
F.R.C.S.,and Prank F. Schacht, B.A., M.B.Cantal>., were
admitted Follows of the Society.
AlberEhrmaQD, L.B.G.P.Lood. (Southum], and Godfrey
P. Reid, M.D.Dabl. (Orange Pros Stato), were declared
admitted.
The following gentlemen were elected Fellows of the
Society; — Arthur Henry liobinaon, M.O.Durh.; and
Bcglnald Huno Williams, M.D.Load.
A UTERUS SHOWlNOr THE EFFECTS OF A
GANGRENOUS FIBROID.
By J. Bland Sutton.
In October, 1880, I was asked to see Mrs. , aged
iS yenrB, in conRaltation witb Dr. 8. L. Smith. A dusky-
red tumour, as large as a cocoa-not, projected from the
AXtS FKBtWDRn BmPAK.
173
the putrid \nii»s romuved, uiul tliu utcTiiiu ciivity froaly
20W.
irrigated wttii aLUliiuate KOlutiuOj 1 lu auyu. for somo
days the patiout prooiisod to do well, but on tlio ovouiug
of thu lifth day after tho opcratiou tho tomperature sad-
doidy fell fi'oiii 101° tu !)7", aud sliu ^eouiuJ abuut tu die.
In twolvti lioufs tlie collapHe pasaod uff, poritunitiu auper-
veuLid, utid death occurred ciiue duys after the remgral uf
the fibroid.
The t-xnminatiou of the utorus was very insbnictlTo.
Its walls were greatly hypertruphitid : on the posterior
wall, near the fundus, vftun seen the I'liiiiided etimipor the
tibi-oid quite healthy and Eiealod. It was suiToundod hy
the ulerine mucous mouibrane iu a sloughing condition aud
nearly loose. The sloughing process had involved tho
iniicoiis membrane of the Fallopian tubou, aud portioua oF
this putrid ti»fiuo liad protruded into the cavity uf the
peritoneum aud iuduced fatal peritonitis. Had thu abdo-
minal oHtiam become occluded by ibe iuil animation, as so
frequently liappcns in cases of aalpiiigitia, this woman
would probably not have died,
Mr. Alhaj* Dorak ubnervwl that Mr. Sutton's spi'cimyn
provvd how till' iK'rituu*!iiui mij^bt Wcouu.' iufocited by the
enimncc into its cavity o£ putrid tiubblancuH wbit^h ori^iniklly
became putrid within tka uteniN and ]>aHNf>d iiiti> the jierituneiini
through the FaLlojiiaa tube. Sentie jierilunitis after childbirth
aud aJEter o|H-niliuuB iu the uoit<hbuurhi>u>d vl thu ccrvii, luvBt
probably arose iu the sauu; wny. that is by poiHonous fluids
simply paHsing up tha tubes. More complic'a,toa doL-trines an to
peritoiioal infection through intlammaliou be>;iuuiu); m the
eudumelrium, and t-xteudiiig thruugli the inuHi'iilar cubstutice
to the perituneuui, or to the pelvic (juaoeuLive tJBSue were less
likely to be correct.
AXIS PHKSSUHB BINDKB FOK U8H; iJUKlNG
LABOU U.
By Dr. AfMAai), Ipswich (introduced by Dr. UoKituCKS],
Dr. Lkwe Its eaid that the most itnportftut question seemed
to be as to whether vagina] hysterectomy or supra- VBgiiial
aiuputution of the cervix was the better operntion for those
cases of cancer of the cervix suitable for radical truatment.
In determining this questiou tlie two chief factors to be con-
sidered were— Ist, tlio relative mortality of the two opera-
lions ; and 2iid, the prospect of immanity against recur*
ronce offered by each of them. As regarded the mortality
in total extirpation, tliurc waH a. greater risk of septic
iafeotion owing to tho free opening into the poritoneum ;
a much greater risk of hsemorrhage, both during the opera-
tion and subsequently ; and COQ? plications such as adhesiona
between the uterus and intestine or omentum might be
met with. Further, as pcgarded the duration of the opera-
tion, and therefore the shock experienced by the patient,
total extirpation compared unfavourably with eupra-vaginal
amputation. Although some Gerniau operators reported
the mortality of total extirpation for cancer as 5 per cent.,
no such favourable record could be ahown in England.
Dr. Lewers urged that, in the case of an operation that had
been extensively performed here, Englieli rules of practica
ahoold be founded on English statistics. He belieredf
from hia knowledge of published and unpublished cases,
that the mortality of totaJ extirpation for cwncer in this
country was much nearer 20 per cent, than 5. Dr. Lewera
had himself performed three total extirpations, two for
primary cancer of the body of the uterus, which recovered,
and one for cancer of the cervix, which died. He had pei^
formed 8upra-vagiual amputation of the cervix seventeen
limeB without any death.
VAGINAL
HTaTBBECTOMTr
175
Dr. Lewers reminded the Society that at its last luoet-
ing so higli an authority as Dr. JoHa Williaaia spuke of
t]iii chances of curiDg cases of cancer of the uterus hy any
operation whatever as " iofiiutesimal." On the other
hand, a large proportionof the cases operated on in Gemwiny
were free from recurrence for so long a time after operft-
tion that if thej were renlly caeeB of cancer tbey might
fairly be considered as cared. The only possible explanit-
tion seemed to be that many of the&e cases were not really
instances of cancer. Referring to his own series of
serenteen cases of supra -vaginal amputation, Dr. Lewers
soddin fifteen of them the operation had been complete —
that is to 8ay, it was believed that all the diseaeed tis&ne
had been removed. In these fifteen cases the results as
regarded recurrence had been aa follows ; — Four cftsos
were known to bo quite well two years after the operation,
six eases were known to have had a recurrence, three cases
were lost sight of, aud two other cases were free from re-
currence, but had only been operated on within the last
twelve months.
Omitting these latter from consideration, and counting
the cases lost sight of as cases of recurrence, there remained
four cases out of thirteen well two years after operation —
that is to say, 30 per cent. This result, ao far as he knew,
was quite as favourable as any obtained hy total extirpa-
tion, and it had been secured at no cost to life. From
what he had read, aud also from the experieuce of his own
cases. Dr. Lewers believed that in nine caeet! out of ten
the supra-vngioat amputation was the right operation in
early casee of c&ucer of the cervix.
Dr. Waltkb Ghiffith stated that, from examination of
specimens and experience of cases, he had formed the
opinion that the kind of cancer was a very important
matter. The only cases which conld be considered really
favourable for removal were cases of epithelioma, and it
did not make much difierenoe which operation was adopted
90 long as the whole disease was freely removed. Ho had
loHt ono patient frmu liuii]ioi'L''h.ii.go iiftei* the n-'inaval of
|)i'(?fj8Ure forceps, tbe bleeiliii^ bogluniug w)iil»b I.Iig vagina
wa« being duiiclietl, Tlio ri«k of tbis occurrence would
uiakb liiiu very ciiutious in Iheir use in future, except aa
ttUxiUnry uiu'iuia to ligutui-t-M.
I
Dr. Macnauuhtun Jonks, having rofcrred to tho iucrcusod
respousiLiility Ucvulviug oii tliouo wbosu iiilvice was swugbt
iu cui^eu of canoer ol tbo wouib in the face of tho aacer-
tainod rosults of vn^fiiml by sfct' recti iniy, saiil lilmt hitherto
ctiiiisi'r (if Uie uti^riii^ bud been Uio opjirobriuui of gynm-
coliigy ill Uk! futility uf the vfiriuut! opwrativc procetluros
piiM.' tiMLnl for 1(8 euro, llis tiwii record, iiicliidiiig timny
Compli'lti Iiigli aiiiputatidiiH, hud btieii lUL-hLiicliuly. Ho
argund that Dr. Jubu Williu.ms's conclusions as oppu!(L>d to
bystt;rectomy were faUacious. Tliey might he dividttd into
tbrei; heads — statistical, pathuloj^csl, and cliuica-l. Ah
agaiusl Dr. Williams'^ assertion that tbe (ici'mau statistics
were prat'tically valtteless, being based on hysterectomies
perfoniiod for other cases than cancer, Dr, JoueB qiiotod
tbe stdtistic* piibliehiHl by Drs. Muiide mid Wella up to
188!l, Huil t'olloet-ed from tbe ru^iulbs of 183 cawoa of uancer
uptiratod on iti (jonnaiiy, Friiiict*, Aniorica, :ind Eiigtuud.
Of lliesu tliert- wlm-q Ivvwiity-two deaths after operatiou, and
ill only twtnty-tbree was reciirrcuce noLud up t.o tht; tim«
of pubEication of bhctio ctisee, and in thirteen rccovory wax
Haid bo he pormnneub, Coiisidoi'iug the chnrncter of tlie
operation and its comparatively recent intvoduction, he con-
eidered tins record to be very favouralile. Dr. Ciilling-
wortb, in his few cases, bad himself acknowledged the
advantages of osperioiice in operating — as, for instance, in
tlio use of tho forceps instead of lignturo, tbongb Mnriiu still
operuteid by ligatnre. Ig'iiorMuco and bungling, as even
Mr. IjawHun Tiiit acknowledged, were inseparable from
high murlttlity iu t-arlicr tipcrations of this kind. As to
tbe pathological ground taken by Dr. John Williams, lie
demurred altogether from the view that the disease was
8o limited as he declared by the internal 08. The rcneurches
VAOIHAI. llveTIGKItarOHT.
177
of Abol wore quite oppoaed to this view, as also those of
other autliorities. lie Iiad Bt'eii umloubtod ciinea where
the fiiiidu!^ vrns iuvudt^d imd nut Um ]iiiramoti'ium. Tho
uncroJicope was not ut times an iiifalHhIu test, and good
liistologists wure liable to error iit sucli matters. Lastly,
he did uot agree to the cliuicul deductioui^ of Dr. Wiltiaing,
Hu cuuld uot Bou wlij' oiiu aiirgical priiioiplu lihould tti
applied tu uauvcr of the Lreunt aud nuuthur to citucur uf tliti
uterus. He ugread to thu pruposibioii uf Dr. Lewors that
tho proi9ptJi:t» from tho two operative procedures, hifi^h
n.m ptitation aud hysterectomy, should be put plainly beform
tlio |»itieut. Fur hiiiiKL>|[ liu fi^lt that iu ii eana in whJcb
truo citncfir of the ute^nm wiis oucu cluarly deuhiriid in Ibe
corvix uteri, and tho KUrrounding tiHsuutj wm'u licidtb^, he
ttliould ]eau to the side uf hysterectomy and not mnputa*
tion. It gave the woumu the best chunce both of pm-
longing- aud siiviiig life.
Dr. T. C. Uayes thuLight lliat ciirciuouiu. of the ultvIx
had a strong tendency to iuvude the body aud fundus of
the uterus. He seldom found that the disease wae limited
to tbo cervix when patifrnta catne under obRervntion.
Argument againsl viigiuul hyHlerectouiy based upon itiioh
HmittvtiouK being" tho rule, or oven oonimoii, wii.s uusouud.
Jf there were Hssurances of thin liuiitabiou, vaginal ex.tir-
patiou tihuuld not be rofeortttd to. It was a uiuvE more
dangerous opL-ratLon tbau atuputuliou, though iu the future
its dnngetH would probably bo luBsentjd. Ue could not too
strongly urge that patients nhould in nil canes bo made
fully aware of the scrioua dangers, audL not buoyed up with
false hopes of a pormanent care.
Mr. Kqektoh Jbhninos reuiarkud that lie wonlid like to
seo broad priuuipluo dinuuHHed fi rut, and meUiodx of detail
and cuniparisouii between different uperatiuud afterwards.
By Iho courtesy of three or four uieuibern of Uie profes-
Rtou who had auttwered his incjuirles, he had in hie po««eB*
ttioQ noteH of a few ca«e8 of cancer in which after u lapse
178
Vaginal HYsrERHCTouv.
of five years — in one case of thirteen years — tliere hatl been
no returu oi the disease. These were cases of ciincer
affecting the breast, the lip, and other regions of the body;
but he contfindcd that ths carability of the disease by
extirpatioD when it had attacked soms parts of the body
having been established, there was no reason why cancer
of the oterus should not also be auccesafiilly dealt with by
surgical operations. The only difficnlty to be eaconutered
iu cancer of the cernx uteri was the peculiar anatomical
snrroundings of the locality under oonaideratioD. He
agreed with Dr. Playfair, who had said that only a bold
lann could always venture to diatinguish confidently be-
tween cancer of the cervix and other non-malignant con-
ditions which ao closely simulated it. Here he would ob-
serve parenthetically that, upon the authority of Dr. Play fair
and of Dr. Bury, an uadoubied case of uterine cancer has
been reported cured by Chian turpentine mixture. Some
speakers had commented upon the tendency of uterine
cancer bo spread laterally into the parametrium rather
than towards the fundus ut©rij and had urged the useless-
neas of removing the fundus as well aa the cervix. Mr.
Jennings accepted the statement as to (he usual invasion
of the parametrium in a lateral direction, but not the in-
fer«uca as to treatment drawn therefrotu. He maintained
that the entire organ should he first removed, and the
surgeon's hand suhaeque^ntly inserted into the pelvic cwvity,
by which means diseased portions of the parametrium and
the ovaries could bo drawu downward and removed. He
was the first surgeon in this country who had success-
fully employed forceps to arrest the hemorrhage from the
broad ligaments iustcad uf ligatures. Inao doing he bad
adopted the suggestion of Sir Spencer Weils More than
u year ago he treated a case of epithelioma situated at the
orifice of a hypertrophically elongated cervix by amputation
sufficiently higU up to ensure tlie incisions passing tbroagh
perfectly healthy lisaues. Such a case was, however, rare,
and, as a general rule, Mr. Jenuiags advocated total ex-
cision of the uterus after the method he had described.
VAOINAL UYSTKIueC'tOHT.
179
Dr, GuiPriTii here imiuiriug wimtlier ia the oaao Mr.
JtinoiugH bad just referrod to, the diagiiuHiH was confirmed
by microscopic examinatiouj Mr. Jenuinga replied in tbe
negative, but aaid that tlie diagnosis rested upon the
authority o£ four surgeouis.
Dr. CuLLiNOWQBTH, in reply, expresaed the pleaanre it
gavo liim to see Dr. Graily Hewitt in the chair on. that
occasion, Dr. Uewitt hariug been on& of the only two
speakers who, when the subject of total extirpation of the
uterus for cancor was discusaed by the Society in 1886,
had cofvaiued from deuouuciiig the operation as unjustifi-
able. Dr. John Williams had nrgned that the statistics
of the Geroian operators were umeliable on the ground
that, in Germany, ragiual hysterectomy was performed not
only for cancer, but for other conditions. This would
have been a sound argument if the German operators had
beon in the habit of mixing the cases in their reports.
But it was not so. The statistics of tbe cancer caaea wore
given separately. Let them take, for example, Mtiach-
meyoHfl cases. Of the total number reported (ItiO), eighty
were cases of cancer. Only four out of the eighty patiouta
died from the operation, a mortality of exactly 5 percent.
Tbe total mortality amongiit the whole 160 cases was 5'4
per cent., so that at Dresden the operation was slightly
less fatal in the cases of cancer, than when performed for
less fierious conditions. Dr. Williams's next point was that
he could not accept the statement as to the disease having
infiltrated the tissues above the oa internwrn-, becauBe of
the difficulty of deciding tbe precise lino whore cervw ended
and corpiu began. He thought this was a somewhat
poor argument to bring forward, for if the inOltration had
esteudcd so near to the vs internum as to raise a doubt
whether it had or had not passed the line, surely the
point for which he (Dr. CulUogworth) was contending
might be conceded. As a matter of fact, however, in
three oat. of the four specimeus there waa no manner of
doubt as tu tho position of the oa internum; it was reo-
180
VJLQINAL aYeil'KElKCTOHT.
dered ovidunL hy Uio uwhbI constriction, ne well as nscer-
lutuvd by uL-vumtti tuesisuruiiiout ; wbilo in tho Funrtb cuko
it ImJ tu be tietermiiiud hy mt-'iuiu i-uiUE'iit alono, tlie glands,
Dpon wbicb Dr. Williiims thuugbt the deter mi nut ion sliouM
entirely real, were too tar involved iu tUe diseiijic to allowr of
tluiir ideiitilicHtiou. Di*. Williaiiis next naid thnt no bettor
evidence could have becu udduced in faymir of liis view
timii was uit'ot'dcd by tbe fivo lauueuui-sptjcLmeus on tlie
ta\}h. Ho muBt say tbat lie listened to that ictiiuik with
aniHZt>mRnt. Did Dr. Willintim nn]y ac-knowledge tboso
tissiiUH to 1)0 (raiici-roii8 wliicli liiul bouunie ulcornted and
doxtmyttd ? Siiivly lie wonld itllow tluit thp tiBsues uften
Wcame iuCUrated to a coiiNideniblt! (list;ince beyoud tbe
limits uC Lbo dL-Htruclive process. Tlit- L-laitu tliat tliesu
specimens disproved the tendency of tbe disease to alTeut
tlie carpus lUeri could uofc ior a moinenl. be siistatned, for
iu two of tbem tho InBItrntion bad exteiided to witbin a
quarter ui an iiicli of the fundus, in one to within one-
third of an inch, and in another to within an inch. Again,
iu the remaining' spocitnen, thougli it was certain that
tho uppBi" ptirt of the corpua aa well asi the lower had be-
come iuvaduU, it was found imposHiblo, owing to the age
of tha prepiiratiini, tu defiiit; the limit by precise inpasure-
nient. With regard to tbu recominuudaliori that the
operator should be guided u» to the extent of his opera*
tion by tbe conditiouH discovered ict tho timo of operation,
it was one tliatj though it Houndod well in a speech aud
looked well on paper, could seldom be carried into pruc-
tice. [f a patholo^stj la the quiob of bis laboratory and
with the specimen in bis hand, hesitated to define the
limits of the cancorons infiltration until he had had an
opportunity o£ submitting it to cortaiu proeeBsoB of hard-
ening and Htaiiiing, and of exHUiiinng it iiudor the micro-
Hcope, how waa an operator in the midst of an anxious and
difficult operation to be expected to decide such a matter t
It wait often quitu impossible for liiui to do so.
Oue of Dr. Williams's arguments iu favour of tbe ao-
jcallud minor opcratiou was derived from the fact that
I
VAQINAt HTBTBRKnOMT.
181
wTten tlie disease recinred after high ampntAtion of the
cancerous cervix the rccurrenco gcaL-rally took place, not
in the uteritie stump, but in the parametric tissue. This
ntidouhtcdly oonatitutod a more dillicult nrjrmQcnt to mnct
than thoso that had liitlierto boon doalt with. The pho-
nomenon had its analogue in tho breast. IF, iu the ease
of a CBUcerous hroast, a snrgaon contents himself with ox-
Ctmng tho difteased portion instead of removing the whole
gland, any recurrence that vn&y take plaoe does so in tho
Bkin, or gtanda, or other eurroundirag tisRUO, rather than
iu tho stump op unromoved portion of tho breHst-gljiiid.
It was a curious pathological fact, and one that had ao far
received no adL-quate explanation. But the knowledge
of this fact detem^d few eargeona from removing the
entire brennt in cases of cancer; ond, as a matter of ox-
periencp, the surgeons who, like Dr. Banks of Livorpoolj
removed it most freely were able to show the largest
percentaipe of cures. Moreover, although it was the rule
for recurrent nancer of the ei:rviir utKri \o attack f>ther
parta tliftu the uterine Htump, this, as Dr. Williams him-
self had shown, was not invariably the ease. Was it not
therefore wiser to extirpate the eutire organ rallior than
run tlio risk of recurrence in the ntump ? Dr. Williams
concladed his remarks by prophesying that a recnrrrnre
would take place in all tho cases reported iit the paper.
It was highly probable that that prophecy would be ful-
filled. It was unfortunately only too true that rccurrenco
does occur after tho great majority of operations for the
removal of cancer, in whatever part of the body thoy are
nndortaken, eo tliat it becamo pretty safe to foretell ulti-
mate difmppoiutnieiit iu any givon tioriefi of three or four
cases. Mr. HutlJn had shown that even in «o nccesHihlR a
region aa the bnnist the cures after operation for cancer
do not exceed lOto 15 per cent. ; and if that were true of
the brenHfc, where the part could be freely removed and
diBoaeed glands extirpated, what might bo expected in
the caac of iiiternnl urgaua like tho ntcrus, whoro thu
cooditiona iroro so much 1i-»b favourEUilc? But even in
182
TAOnfAL HTSTEBECTOMT.
thia matter of recurrence the operfttion of vaginal liyste-
rectomy haJ completely jnstifieil itself, for experience had
bIlowii that the percentage of cares was actually higher
than in the ca.se o£ removal of the breast. Taking the
Dreeden atatistics for example : of the eighty cases of
total extirpation for canoerj no fewer than twenty-aeiren
lad lived for two years and upwards without any sign of
recuiTscoe, and therefore, according to the pule Dp.
'WilUamB had laid down, or at any rate had accepted,
might be prononnced cured. Granted, however, that the
chances of effecting a permanent cure were comparatively
small, was the operation therefore to be abandoned T
Had it BO temporary value even in those cases where the
disease unfortunately returned and the patient ultimately
died from itf Let them take the case of the woman Knight,
the first of the short series which formed the baaia of
the paper. When the patient was operated upon ehewas
suffering from continuous hfemorrhage ; her life was a
burden; she was thin, careworn, wretched, and unable to
attend to her household duties. It was now fourteen
months since the operation, and although there had been
signs of B recurrence of the growth after the first eight
months, and a permanent cure was therefore out of the
question, so slowly had the recurrent disease developed
that the patient had even up to the present time been
almOBt entirely free from hasmorrhage j there had been
little or no offensive discharge ; and she had been enabled
to attend to her household duties and to the wants of
her sick husband. Did not this repay her for the opera-
tion ? Did not the comfort she had gained during these
fourteen mouths compensate for the risk T The value of
an operation was not to he measured merely by the chance
of its effecting a permanent cure.
He now turned to the remarks of Dr. William Duncan.
Dr. W. Duncan commenced by expressing his want of
foith in German atatistics. The questions that had been
raised could only be settled by statistics; and as wo must
have them, ho had, in his paper, quoted the moat recent
I
TAQINAL HTSTERICTOMT,
183
stAtiakica of two op three operators who had had a very
large experience. Those operators happened to he Germans.
Surely the figures were not on that account to he pnt
lightly aside as unworthy of Credence. Anticipating, how-
ever.Bome such objection as that raised by Dr. W. Duncan,
ho h&d been cfireful to select amongst the many aene& of
fitfttistics available two sets of cases only, where opera-
tions had been performed by iQeo well known to the en-
tire profeesiou as eminently trustworthy and honourable,
viz. Leopold (by whom many, if not indeed most, of the
operations reported by Miinchraeyerhad been performed],
Mnnchmeyer himself^ and Xaltenbach. The statistics of
these men were beyond cavil. He had quoted them, not
because he shared Dr. W. Duncan's diatrnBt of German
statistics in genei-al, but because he desired to deal with
figures that every Knglish gynsocologist would accept.
Dr. W. Duncan went on to say that the museum-spcci-
meufi he had placed on the table were valueless, because
in each of thoui the diHease had advanced to a stage when
no one would think of operating. His answer to that
was that the specimenB, as Dr. Duncan most know very
well, were brought forward with a definite object, wholly
uuoonnected with the qaesfcion of operation. They were
produced to show that cancer of the cervix, of both kinds,
if allowed to run ile natural course, nltiuiately invaded
tbo body of the ntenis. All the five specimens had beeu
taken out of tbo jars by Mr. Shattock, aod sectioos cut
from them had been submitted to a prolonged and careful
mioroBcopical oxaminatiou to determine the particular
nature of the growth in each case. The result whs re-
markable, in that it showed that of the four epecimeus
in which the chauges effected by maceration still per-
mitted a diagnosis to be made, three were examples of
squamouB-celled carcinoma, and only one of columnar-
celled or glandular carcinoma. Bo that we had here three
instances of the ultimate inflltrattoa of the corpus ulerif
to within a very short distance of the fundus, by that form
of cancer which was considered even less prone than the
184
TiaiKAL BTSTESKCtOltT.
Other to extend in t\td direction. With re^rd to the
condition of the utero-sacral li)^nicDts,aad Dr. W. Daucan's
qnc«tion *a to irhcthC'r this had been a!>ecrtninod, he begged
%n refop to tho reports of the caws thcmsolvea. Tn two
coflos it*wau known before tho opcrBCion that the ntero-
iwcral h'gaments were involved in adhesions, bnt those
adhRHianH were of an inflaintnatory nature, and though thejr
added greatly to the difficultjr of the operation (hey were
Dot considered as contTn-indicattoon to it. The state of
the nten>sacral ligaments was not the lent aa to the pro-
priety of opentting. Fiaatly, Dr. W. Duncan exprepsed
bis bfltef that in cancer of the cervix the disea&c did n<4
spread into the body of the nt^ms. Expreasiona of belief,
liovrever, did not cnnstitnte an argument. Dr. Duncan
mnat produce ovidcnco iu support of his belief beforo hia
opinion eould be sccopted b» of any value. Ho had not
done tliiBj neither had he given any good reaKon for not
accepting tho evidence that had been adduced in itnpport
of the contention of the paper.
With the opinion expressed by Dr. Sinclair that, as
regards their difficulty, there vra.>4 scarcely anything to
ofaooM between the two opemtiona of total extirpation and
«apr»-Taginal ampliation of tho cervix, he entirely (^reod.
Up, Sinclair pToforrcd socuring tho broad ligaments by
ligature to using tho elamp forceps for that purpose. The
points in favour of tho clamp seemed to him {Dr. Culling-
worth) to 1)0 (1) tho great waving of timo, amounting pro-
bably to twenty minntcs, which was a. not unimportant con-
sidct-aLlon in an operation of thi» kind ; and (2) the larger
extent of the slough in the parametric connective tissuo
ant«ilcd by its use, which was n distinct advantage whore
this tisHue was beginning to be iriYndctl by the di-ieane.
The romarkfl of tho other spcakcrfl had in a grt'at mea-
SBre been replied to in the preceding obaer^'ationfl, and his
fnrther cwramentH njion thorn would accordingly be very
brief. Dr. LewL-rM had Hpoken of the danger of total ex-
tirpation as compared with Hupra- vaginal amputation, owing
to the nocossity for opening intji the peritoneal cavity in
rAOIHAL HTSTZRECmMT.
nh
the former opei'ation. It was, however, by no means
uncoinmoii for an opnning to be accidentally made iiitu
Douglas's pouch in sapra-vagiaal amputation. Wlieu tliat
accident occurred it was treated by the advocates of supra-
vaginal amputation as a matter of Httle importnnco. If
tlie opening of tho porituneum countituted an element of
danger in the one operation anrely it did ^o in the other. To
his mind there was much leHS danger in opening the peri-
tooeal cavity where this was followed by free drainage, as
in the caae of total extirpation, than where the peritoneal
wound was covered up, as in the case of such a wound
being made daring sopra-vaginal aiiiputnliou of tbec«rWx.
An instance was given whore a batton-holo opening, acci-
dentally made in the poritoneum of DoiiglaB's pouch, dur-
ing the operation of xupra-vaginal nmputAtiou of the cervix,
had led to a fatal result. The time had gone by for dread-
ing the peritoneum, and he could not admit that the free
opening of the puritoneni cavity added to the dangers of
total extirpation. Dr. Lowers, in coinpariugthe mortality of
the two operatioDH, bad quotod figures that wito ultogetbor
incorruct. The mortality front Bupra-vnginal amputation,
80 far from being nil, wae, at present, over 7 per ceot.,
even in the hands of the most able oper&toni ; while, on
the other band, the prt*Beiit mortality from total extirpa-
tion was not 20 per oeut., but 5 per cent. Dr. Lewers had
risen to explain that the mortality of nil in supra-vaginal
amputation was taken from his own Heriea of cases. In
that case he shonld have said so. He ought also to have
told them how he arrived at his estimate of the mortality
of total extirpation. Perhaps be would say whether he
bad taken thai alno fi-om his own experieaco.
Br. LtWKKS. — No, my own death-rate from total extir-
pation ha« boitn abonl iA) per cont.
Dr. CuLLiBiowoRTii.— Kvidcntly, tlien, the compArison
was in every sense unfair. Dr. Lewerit was of opinion that
English practice fihould be guided by English stnlistics.
He (Dr. CnlUngworlh) was of an entirely contrary opinion.
The number of totibl oxtirpattons that had been performed
VOL. XXXII. 1^
186
VAOlKAt. HyaTHBKCTOMT.
in England was vcrj small incomparisoti witli tte iiumlter
pert'ormcd lu otlier countries, and it would be ridiculous
not to accept the tcnchin^a of larger experience. In tlio
case of otlier operations we were guided ^bltnost entirely
by the experience of our German brethren. Let tUem
take for example ths modern Cjosnrefiu section, which wo
owed to Gorraaiiy : and Popro's oppratiun, for which we
were entirely indebtod to Ttalv". NoItLer of thettB opera-
tions would ever have been performed in this country had
English operators been guided by KnglJsh statiHtics.
Operators in tliis and in every other country ought to he
rendy to profit by tlie results of others, whatever might be
their nationality.
Dr. Hayes had laid atrees on the obligation that rested
upon 118 of putting tho chances fairly and fully before a
patient. With tbis he heartily concurred. Not only
shoulrl tho risk of an immediately fatal reaiitt b© explained,
but the strong probability of recurrence.
The last speaker, Mr, Jennings, had very properly said
that we ought not to limit ourBcIvoa to one operation or
one method of treatmenti but to be rejidy bu adopt one
operation iu one case and another in another. He (Dr.
€ulling%'orth) had hinted in his paper, aud he might,
perhaps, with advantage have given the suggestion gi-eator
prominence, that while the partial operation might be
RuSiciQut in motit caues of fi(|uauoti8-ceI]Dd carcinoma,
total e.xtirpation was the only Bate method of dealing with
glandular carcinoma of the cervix. If that view proved
to be correct, and the evidence at present available cer-
tainly »cemed to point in that direction, each operation
would have its own proper sphere of uFiefulneas, and a
mioroacopical examination of a portion of the diseased
tissue would decide which operation was called for iu any
given case. It would be narrow and unscientific to main-
tain that one operation was alike suitable for every caeo.
Dr. Sinclair bad well said, in a paper lately published in
the ' Practitioner,' that until some berter method of treat-
ing cervical cancer had been devised, the very hopeless*
VAOINAL HYSTBRECTOUT. 187
iiess of these cases if left to themselves would lead men
to adopt operative measnres for their relief. What we
oQght, then, to aim at was to discover which operatioQ
produced the best results, and for what class of cases each
operation was the most suitable. The paper that had been
read was intended as a contribution to this inquiry. He
thanked the Society for the kind manner in which the
communication had been received, and for the interest
that had been shown in its discussion.
JUNE 4tb, 1890.
AmxD L. Galadih, M.D., President-, in the Chair.
Present — 43 Fellows and 6 Visitors.
Books were presented hy Dr. Andrew P. Curnor, Dr.
Herman^ and the Royal College of Surgeons of England.
Augustiia W. Addinsell, M.B., C.M.Edin. ; and Robert
J. Carter, M.B.Lond., were ndmitted Fellows of tho
Society.
Hugh Smith, M.D.Lond. (Bow), was declared admitted.
The following gentlemen were proposed for election ; —
Alfredo AntnncB Kanthack, B.A.Lond,, F.R.O.S. ; and
Prodoriok John McCnnn, M.B., C.M.Edin.
THE GLANDS OF THE FALLOPIAN TUBE.
By J. Bland Sbttoit.
Im 1888 I plocod before thia Society evidence and argn-
mcnt to snpport my opinion that the familiar rngie of tho
raucous membrane lining tho FatlopiaQ tubes are in
eesonoe glands. On that oxjcaeion it was urged by one
Fellow (Mr. Alban Doran), a capable critic, that 1 ought
to have supported my argument by adducing evidence in
the shape of accurate drawings ittustratiog the characters
of thesti glands iu iho Fallopian tubes of other mammals.
VOL. IXZII. 14
mo TBB OtASne OF TBE PALt.OPrAK TOBB.
As time and opportuuit; pcrmittod, I bnro bad some
feitbfal sketches prepared, by a competent drftnghteraan,
from eectious made under ray personal auperiuteiidenco by
Mr. Kennetb Lawson and tlie Bkilful assistant to tbe museum
of the Middleeei Hospital (Mr. Pollard).
The specimoDB shown as types were taken from the Fal-
lopian tube of a Macaque MonVey, Mncncus rke»uj», and the
Panolian Deer, Gervm eltti.
FlO. 1 .— 'Tnin«verie Miction tlirougb tie Fiillopian tnlHi of a.
Mncnquc Monkey, M. rhvmt, to >bou- tU» glunil-clmtcn.
The nteniB of a Ma«a(]iiB may be best doHCribcd as n
rainiatni'o hnman uteru.':. A tmnsverse section taken from
the middle of its tiibo is shown in Fig. I.
This specimen shows vei-y well the cluater-like arrange-
ment of the glandular acini, each presenting a single layer
of large, regular sub-coluiunar epithelium.
Au oxamination of a large number of Fallopian tubes
shows Unit the middle of the tube — that is, near the junc-
192
THE (irJNDS OP THE FALLOPIAN TDHE.
ap'Sciraen, sliowing mi isolatod gland from the Fallopian
tube of the Panotian Deer, Ceri-vjt eldi, is sketched in
Fig. 2. It is upon the type of a compound racemose
gland with a single layer of large regular columnar epi-
thelium. These conipJex recesses extend around the whole
Ctrcnuiference of ttie tube, and, as a rule, eight to twelve
maj be counted in a single section. It is possible that
^•L^^
CAVITV
OF CY9T
„*U>?*
Pia. a. — Mici'utMpical cliBTacl^rH of « E^llopian ndenoina
(Dornn'a caae), tor nitn]iariBan with Ftg. 1.
the epithelium oE these recesses is furnitihed with cilia, bnt
it is not so ensy to determine this paint, atthongh it niikj
seem n simple matter to those nut experienced in practical
THE eUNDB OF TBB FALLOFUK TUBS. 193
hiatology. These facts are of interest in relation to adeao-
mata ot the Fallopian tube. The first specimen of this
apparently rare form of tumour was described by Mr. Alban
Dornn as a papilloma of the tube. I Lave had au opportunity
of re-esa.niiniiig this tiimonr microacapically, and find it to
be an adeiioum, and the glaud-strurln i-u miuiics that of the
normal gliuide of tho tube. A sketch of the inioutt struc-
ture of this tumour is gi7eu in Fig. 3, Eor sug-geKtisc cum-
pari&ou with Fig. 1 Eroui the Macaque.
It may &oom to mauy that the glandular nature
of these receesea is merely n question of interpretatiouj
and not so much s, qut^stiou of fact ; it is neverttieleBB
a matter of sume importance in dealing with the patho-
logy of the Fallopian tube. In toncludiug this brief
com muni cation I Hubmit thut these recesses in the tube are
as thoroughly glandular in their nature, arise upon pre-
cisely tlie same plan, and at the same period as those
roucsseti of the uterine utucoua membrane to which all of
UK, withuut any quostioa, upply the term glauda.
Dr. Walteb GBrFFiTH wan plad to find that Mr. Suttou hod,
by his cominuutca.tion that evening, acknowledged the nix-eaaity
for the study of the oviducts of vertebrates as an important stage
in the investigation of the |ir<>g«nGe of glands in the human
FiUiopiaii tube. Mr. SJuttoii musU however, first licfint what
hi; mimiit by a ghind. imd, as Iiadbi-en !iiigge«ted to Dr. Griffith
by an nUIe biBlologiat, bv B]it>uld make longitudiiuil aa well as
traiiHwrBc sectiouti vf the tubu to yaove ibiu puiut. AVbat aj}-
nmrt'd to hv glauda iu trausvL-rBe sectiou were siuiply lougitii-
dinal folda.
Ur, Ueywood Suitu said that the- point brought forwuj-d by
Mr. Itlaiid Button vta of the utniont iiuportancet not ouly from
lhi.> patholu^'itul l>u1 nliu) tlin pliyitiologinal point of viow. It
ti-ndcd to throw light upon tho localUattoii ot the ovnm iu tiinos
of ectopic gestation. It helped to dciuoustratv that thu oviduct
tMiug. like the uterine tiEsue. furnished with glaudH. wiut the
rcul iiidilB of the oTum in siifh cases. Lastly, it indicated that
su-cdled abdouiuul pregu;iucy bcgau invariably as tubal preg-
nancy, and by rupture became abduniiual.
Mr. ALUA.K DoKAN had frequeutly referred to hie remarkable
ciuf of (lapilloiua of the tube, which was published in the
' TraaHActions of the Pathological Society ' for 1880. It provtdd
IM
apopuh:tic ormt.
tlul Becretiotts from the tutju iasuiug tioxn a pstuluiw ostium
might CMlMhjdru-puhtoiiL'um. A tuutaoiruu " Tfao IU>Iatiou of
Hydro-prntoncun to Tabal Diseaw." bowdoa this (act. -wiu pub-
luibvU ID the ' TnnaairtiotM of the Obetetrica] Society ' for 1886.
He abundant secretion indicatHl glands. Mr. Dorun, howerer.
deecribed the disease as " jNi[>illoaia," because be coDsidered it
bomologoiu to the warts skxu arouud tbt; labia tu ciisca of
chroilic gouorrboi-a. lo bolb catK's tbe pa^itkr^ masses uiipvarud
to be not KO niuvb tuoioure as bjpertrophy of uonnol IJMue pro-
diK'od bv cbronic inflatntDatioD.
Hr. Blasd Scrrox, in replv to Dr. Griffith's remarka, said
be had not sbiftMl ground or retranted one single jioint from his
prcTioiiA (^ominnnic»tion on " The Cllande of tbe Fallopian Tubes "
oi the Sociely'tt ' Tran«aetionH * (vol. xsi. p. i07j. Dr. Griffith at
that ttiiiuurf^-d that thm'rideQcefurulBLedbj the oviducts in the
Anphibia, Ibu Shark, CAiffljrra, the Frog, tb»TortoiaL-,Jtc., should
be Donsidered. The oriducts, Mr. S>ittou. said, in these forms axv
in not a few inatancea richly glandular ; but maitY vearsi of obser-
vation among tho Ii^bthyopaida had convinced him thatatiy mor-
pbvloi^iail thi.-ory could be proved bjr rvfcrt'uce to aucb low and
potoutiai funiiH. Tbt- (|iit^«tton nf tiic gUudular nalurx; of the
Falluiiiiin tubes in the humau female (which, by ibe way. were
Dot highly Bpeciali»ed parts, a« Dr. UritBth believed) niuil )>e
■ettled by obtterrations of the parts iu Mammals. The grealvst
difficulty lay in the fact that mauy bt-lier*^ uiurv teiiatriously
«hat they were taught than trusted to the evidcructi of their own
seosefl) and it was waate of time to argue with such extremely
couservative minds. Comparative anatomy, embryology, and
physiology indicated moat eniiiliiil iwilly that the recessoa of thu
Fulopilui tube were not mere foUiiigs uf tliv tubal uiucuu^t mem-
tnane. but gUoda. Dr. Griffith also asked for a dL'fiuitioii of
a gland. This detinitiou was fumistied in tbe * TransuctiaD»,'
Tol. XXX, p, *21t). Uuc« 6, i>, lU. 11, uud 12.
APOPLECTIC OVUM.
By Ajiakd Rovtb, M.O.
Dk. Auakd Rocto showed a recent 5p*jciinon of apopleiy'
uf the dccidua, from a Riultipara aged 42. She Lad borne
three childreD, the lost five years ago, and had pusaud two
" fle»ihy molee " since ttieu.
Wheu under Or. Routh's care, in Jauuai-y, lS90, she bad
UTKKDa AND ADHBRBNT PLACBNrA.
106
sufTered froii] Uvo slight lia3moiTlia.gi;a, pvecoded by three
muullm' fiiuenorrluBft. The uterus was eiilargod to the
aiise usually altainetl at tite third mouth of g^statiou, but
felt hard, aud there waa no appreciable comproseibility of
itB lower scgmcot.
The patioiit wits ordorad to use iodised vag-inal douches,
and lu report sLuuld auy LajiuoiTbago oi- paiu oucur. For
tho following four luoutlis sho wan regular, iiud ihuu
passed thiit "mole," accoitipauied hy much btemorrhago.
Tilt? ovniii bad died nbout thu third week, and the dcciduik
had xemaiued quiescent til] tbe seventh month.
UTEKLTS AND ADHERENT PLACENTA FKOM
PATIENT DYING OF I'Ui^T-rAItTUM H.«MOR-
RUAGE.
By John PoiLUfs, M.D.
Tub patiout, aged 87, with three liviug childreu, waa
delivered by craniotomy ii year ago iu coiia«quenuc of a
large fibroid in iLe ant-erioi- wall blookiug up the pnlviis.
Dr. Phillipa measured the size of tho tumour immediately
after labour (the index Soger being passed into the uterus),
aud it was apparently of tho size of a cocoanut. She was
warned if proguoiicy again occurred to keep herself under
obiwrvation. This iilia failed to do^ and ber medical
attendant vms CBllcd iu haste to find her moribund from
hffiiuorrhage, a full-time living child born, and tlie pla-
centa closely adherent to tho uterine wall. As much uii
po»siblo wa8 removed, but she died from tlie excessive post*
partuiQ haiuorrhage within au hour.
The post-mortem showed tho uterus large, tiabby, and
extremely blunched. The rctBaine of the placenta, which
was )iituat(>d ovortlio site of the previeualy existiug Sbroid,
were intimately adhureul tu the uterine wall ; this was
much thickened iu that position, but no further ti-aeo of
tho previously existing tumour could be discovered. A
196
FUBDLEMT SENlLll ENDOMUTlMTm.
small iutra<miira1 fibroid was found in the poeterior uterine
Wttll.
Dr. Piiillips thought that the fihroid had uudorgouu
absorption after the inatruineutal labour, Hntl hod not
become hypcrtrophied with the conacijucut preguaooy ;
indeed, that appoared to be the only explanation of the
uuuBUal course of things in this case.
SPECIMENS FllOM A CASE OP PURULENT
SENILE ENDOMBTIUTIS.
By Gr. B. Hbbman, M.B.Loud., F.B.C.P.
Db. Hbrhlun exhibited specimens from a caae having
tbe following clinical history {from notes by Mr. P. A.
Qbiheh, Clinical Clerk). A. H — , aged *Jo, sailor's wife.
No family history of cancer or tumours. One sister was
iiaid to have died from "change of lifoj" licr father
diedj aged 72j from " paralysis j" her raothor, aged 50,
from " dropay ;" a brotlicr lived to 65.
Patient was always regular, except during [irugnaucy
and lactation, till the age of fifty. She wus married when
aged twentyj and had nine children, the last twenty-six
years ago, She had never been q^uitewcll Bince uicuatrua-
tioii ceased; had suffered from rheumatism, bronchitia,
indigestion, giddiness, and liendnebL-s.
lu June, 18Wf, she began to have a. discharge, at tiret
whitish, then mixed with blood, and fi-om the beginning
otrensive. This diiJclmrgo lionceforth continued. At the
tioie it began vhv bad mucli pain in the lower abdomen.
iShe went to a hospital, took some medicine, and the jmiti
diminished. For the last six months she had beeu loning
tiesh.
The patient was admitted into the London Ht>K}>tta.l,
under tbe care of Dr. Herman, January 13lhj l&W. Klie
was strongly built, rather spare, and eomewhat ausBinic.
PDRtTI.BIKT SENILE EMDOUGTRITIB.
197
She complained (besides the discharge and hDomorrhagc
elroady mentioned) of pain in the lower ahdomen and
back, and cough, which prevented her from sleeping. Her
appetite was bad, and the bowels were confined.
Bronchial niieg were heard over the chest, but there
were uo other tiigus of lung disease. No cardiac luurmur
could be heard. There was no ubdumiiial swelling nor
tendorucas, nor any urinary trouble. The urine coutuinBd
no albomcu. On digital examination, the vngiual portion
was found atrophied, the va^-iua smooth and contracted
Bt its upper part. The corns uteri was moveable. With
the speculum the vaginawaa fuund injected, easily bleeding,
and presenting sjjots and patchesaf livid redne58,PHpecially
at the upper part. The cervix nteri was small, dark rod,
and finely granular.
January 23rd. — The pattent was examined under unu98-
thesiu. The uterus was found nioveable, the body some-
what enlarged and more globular than usual ; normal in
poaitiou ; no Uczion.
The cervical canal was dilated with Ucg&r'ii dilators up
to No. 10, at which point the rigidity of the cervii pro-
ventfjd the dilatation from being carried further. As the
canal was opened up, thick, greyish-yellow pus poured
from it.
Looking at the history of discharge, pain, htemorrhago^
and wasting, it was thought very probable that llie dis-
eauo WHS maliguaut. Considering also the opinion held
by itome very omincnt authorities, that the purulent ea-
dometritis of elderly women tends to become malignant,
it was thought that, even without proof that tho coiiditiou
was at present malignant, the removal of the uterus was
tho best treatment. This operation was forthwith done.
The broad ligamimts were securud with PiSan's hietuostatic
forceps, which were left in for thirty hours. T\w patient
i-ocovered without any had symptom!*, and left the hospital
quite well and free from discharge and pain.
The characters oE the uterua wei-e as follows: — It
was 8 inches iu length. The uterine wall was { v( an
198
POHULBNT 9£N'ILE KNDOMKTKITJS.
inch thick. Its innur surface wa& evcrywhurB muootb,
except that it preseaU'ii a small [loijp about tho size of
a pea. Sections were made through this polyp ani the
adjacent surface of the uterus, which Dr. Hermau ox-
hibitcd. The section of the polyp was nbout ^ of an inch
long and projected abont 4 oi an iucli into the uterine
cavity. Tho adjoining surface of the uterus was infil-
trated with round cells bearing Inrge imclei. The tissue
BO formed gmttiially merged into the suhjacont inuscular
tiijgue. TIio roiind-ccllt'd infiltration extended roufi^hly
ubout gi„ of nn inch deep. In it were Mumoroii») glands,
most of which had been cut acroi^a, but somo of which
were cut lengthways. The deepest of thcui was about
■jij of an inch from the suifHce. They were lined with
regular columutir epitheliain, which at uo poiut showed
any tendency to change its clmracter. There wore also
voAfiels opening on the t^urface of the mucoue membrane.
U'he polyp consisted of connective tiaaue, infiltrated with
round cells, though not so closely as th& mucous mem-
brane of the uterns. In the meshes of the connociivo
tissue wore Tory aumcrous glands, tho cavities of which
wore in size from a^ of nn incli in dinuioter downwards.
They were lined with regular columnar upithelium, which
nowliere showed any tendency to change its character ; nor
were there any epitlioliul ingrowths. There was no dis-
ease of the muscular tissue of the uterua.
Somewhat similar aperitnenR, taken from ca^es having
a similar clinical history, had been exhibited to the Society
by Dr. Horrocks and Dr. Galabin (' TmnBactions,' vol. sxix,
pp. 298 and 300). In Dr. Horroclcs's case the question of
cancer waw mooted. In Dr. Gn.labin's the uterus was re-
moved because it was thought to be eaucor. Another
Kimilar Hpeciuion was exhibited by Dr. Matthews Duncan
('Trans.,' vol. xx), p. 64). In this ctise tlie disease was
regarded us uialignuut uutil a micruBcojiiestl examiuutioi]
had been made.
Thcae were the only deaeriptious, so far as Dr. Herman
waa aware^ of the histology of lliie conditiuu.
199
CAllCINUMA OF THE OVAltY.
By C. J. CviLiNowoETH, M.D., F.lt.C.?.
Dit. CoLLiMawoKTn oxliibited a soft tumonr of tlie left
ovary, removed by ojjemtiun (iiufoi-tiiu&lely willi a fatal
result), from a siiigle lady agod (11. A microscopic st>c-
tioii wus alsu h!u)wu. The uterus was euuriimiisly fiilar(jed
frum Hbroiil«, iinJ tlnj ovnrbii tuiuour liiy bciiiud it, deep
it! the ptiWis. A point uf interest in the epuciuieii was
lliat the growth had buret through the- tuuica, albu^inea,
slitting' that structure! and forming a soft mass of new
growth protruding* through tbo ronb. In 8pite of the
enlarged uterus, the patient had not noliced any increase
iu the size of tbo abdomen until fuur weeks previoiiHly.
At the operation thirteen pints of ascitic fluid were
removed ; the iitoriis was left undisturbed. It seemed
most probable that the ascites was the result uf the apou-
tancous rupture of the investing muubraue of the di»caaed
ovary, and the coitseiiueiit irritation of the peritonoum.
No disease was obborved in the peritoneum or in any
other parts than those mentioned. The symptoms after
operation pointed to inte»tinal obstruction; unfortunately,
uo post-mortem examination was obtained.
Mr. Shattock experienced great diflficulty in ontting a
BGctiou, on aL'Couut of the extreme softness of the growth.
The nucroscopB showed the growth to be a rapidly-grow-
ing ciircinooiH, being compo»ed uhuoiit entirely of cpithc-
liam.
UISSKCTION OF A FfKTTS, THE SUB-IECT OF
UETROFLKXION, KCTOPIA \1SCEKUM, liTC. ;
WITH HEMAHKS ON TUE FREQUENT ASSO-
CIATION OF THESE ABNORMALITIES, AND
ITS CAUSE.
W. K. DiKiK, M.U., B.S.
oaamuo VHraicuy ro otrr-MTiiKTB, ckkjit hoktubbr ao«piTAt.|
rKXUCIAX. BOTAL BtMttTXL rOK CHtU^SB]! AXD WOMXX.
(Bcccivcd Febnurj' BlV, 1890.)
{AbgiraH.)
Tub HfwdttiL'U biul Uwn sbowu iu tts reoeDt condiUoa at a
funner mcetiag of tbe Socielj (' Traaaiictioiis,* vol. xxii, 1889,
p. 306), whcD the points worthy of notice in the labour were
lQi;Utioac(l. It wait uow compK'U-ly Ji»«c<;tuU aa<i iIcsLribed.
Tbe vril«r voii«<l(*red all the abDofm^lities priniiLrilr du« t<j
{ailiiru in dt-Ywlopmont of th« biml«r jjart of the gut. He
detaileil thviu, awi eiidcRvoiired to accoimt for each of them as
exanajilcfl of thi? chain of ill results arising; from this defecUrv
devolopmeut. Ho vumo tir tbu following cnijcluBio&e :
Bi^troflcxinn and ectopia vijicorutn majand do occur iadcpcud-
ently. [They may therefore b« assocJatod and yet not have a
cuiuinoii aiu»e.]
Tbe only way apparent in which a common cause could act it
that dcBtnted by Buai-aa and Hurry ('Olat. Tnius.,' vol, xsvi),
oamclyi by shoncningor doing away with the iimbili<'a!<i>rd, imd
thus keopinfj the ahdoiutual Eurfuctf of tliH fwlUK applied to the
uteriue wall and placenta. The latttr, by its close appliuitiun.
preventa closure of the abdun]cu,ki.-t;piii)f ajmrt tbt.' ceutritielallj
growing udgva o£ tbe abdominal walls.
Tbia common caUHC in fuiiuro in developmoat of the hinder
pari of the gut aud its procetses.
m
noTtov OF A rcrrs.
201
Hp applied this theory to the present cane, and congidore^l tho
course of t>veutH vvut ax followM ;
1. Imperfect development of bind gut and therefore of
alloatoiH, rosultioK in (it) abiicncti of umbilical cord, and (?) of
one of the vsaseU (umbitiml artfriea) uorma.lly projeeted on tho
iillaiitoiii ; (i*^) interference with oatflov of iirine, probality at
nllantoic end of iirftcrB. producing riglit hydronephrosis au<l
nbaonco ut' K'ft kidric-y iiud uruter.
2. Rosalting from (n), close application of auterior surface
of f(Gtu8 to pliifioiita and iit^riQe wall, causing —
3. (a) RetrofleiioD, with its efft^cts on the spine (meningocele
and spina bi&du occulta) iit the point of fluiion ; (b) prnaanre-
cSecta on the sid« of the body hold in couta.ct with pkctsuta and
uterine wall; and {r) failure of abdmniiml wall to cloBC.
Tba sabject of tho prcsoat uoto ie a fates wliicli I
showed in its roccnt condition at the November meeting
of thU Society. 1 then briefly monttoned certain mattcra
of intcrent relating to tho labour. The foetus I obaervod.
was a twin of about eight monlhs, born of a 3-para,
witli quite an ordinary history. It Ilvoii an hour. There
was no cord^ but tlio placenta was appHetl closely to
the extruded viscera. It was said that there vtrs only
one amniotic cavity, bat tliis statomont was probably a
mistake, and the plucuntfo wcro, I waa informed, embedded
in a common amnion half an inch apart. The other child
was & female, and naturally formed ; it was bom first and
lired for a few days, dying of asphyxia from no canae
that conld bo detected at the necropsy. Tho two children
woro of the game age.
The external appcnrance of the foetus now exhibited
was roughly described. Tt wa«of small size (or the period
named, even couaidering that it was a twin, being but
18i inches long.
Oencral Appearatice. — Tho head appeared rather large,
but this waa due to diminishod length of the trunk owing
to tho retroflexion of the pelvia, which was ao completo
that tho pubos WAS found a quarter of an inch in rear of
^
202
UIMFCTIOK OF A ?«TOe, THB 8DBJECT OP
the lower end of the coccyx. There was also con^idornble
lateriflexion to the right, and some torsion of the lower
part of tho trunk to tlie left. The integntnents orei* the
nbdominal viscera were entirely absent. The anterior
boundary of this region had been formed by amnion and
placenta, as stated by the midwife. The heart and part
of the left lung were visible outside the thorax, th& dia>
phragm being absent. There was talipes valgus on both
sides, The right arm was well formed and muscular.
The left was very short, with the elbow webbed ; it bore
only two digits.
The external organs of generation consisted of three
wart-like protuberances ever the pabe^. Of these, the'
central one appeared pervious, whilst the lateral ones re-
presented the Bcrotum or labia majora. There was no
harelip, cleft palate, or any other external deformity.
Among the exposed abdominal organs it was easy to
recognise the several parts of the alimentary canal natur-
ally included ■ftithin the abdominal cavity, and the liver
and }r:/f. suprarenal capsnio. Besides these viscera, there
lay in the part corresponding to the right lumbar and
RRTHOFIBXION, liCTOPIA TrSOBRrM, ETC.
203
long, iind 1 incli adross, with a finger-liko process on its
anterior surface flbout J inch long. This body wan placed
bcbind the peritoneum covering the posterior fibdominal
wall. On the other side of the abdomen in the iujyuiual
region was a pale, oval body ^ inch long, looking cxnctly
like B fundus uteri, with a flocculent proooss ou its outer
side resembiing the Fallopian tube. This body was oon-
neeleil with the deeper parts on its inner aide by a thin
white cord ; it induced me to consider the fcetiis a
female, especially as I understood that the twin;* had lain
in a common amniotic sac, audi that the other was a female.
It turned out, however, to be a male. Tht) large oval
mass on the right side was the right kidney, with tho
right lOBticle closoEy applied below, and the right supra-
rcnftl body on its upper surface. The left kidney was
wanting.
Description nf Separate Parle.
Gknito -OBI NARY Tract. — The one kidnfitj, situated as
above deHuribed, was very hydronephrotic, but had a
pervious ureter which led normally into tho bladder. It
was not a horseshoe-kidney, and there was no trace of a
second ureter. The bladder was normal, except in its
relation to the coccyx, posterior to which it lay. A bristle,
easily passed down the urethra and emerged at the centrnl
wart-like protuberance on the pubio region above men-
tioned. 'ITie left t^prarenal body was about one-third
tho sixe of the right.
The fingor-like process referred to above, consisted of
epididymis. It corresponded to the flocculont body on
the opposite side of the abdomen, attached to what waB
supposed to be tho uterusj but was really thy Uft ietttirle.
Thus the right testicle lay immediately beneath the kidney.
Both teHticles had well-formed vasa dcfercntia, which led
to the back of the bladder. The single ureter ran close
to the right vas.
ALlUEiNTAiiY Stbtkm. — Tbo alimentary canal was norinal
SOi
DieSECTIOH 0? 1 FrETDS, THB SUBJECT OP
(IS far as the rertam, except that there was no vfirmifoTm
appendiiD. The vitello-intestinal duct was verj coDRpicuons
And about three inches in teugth. Tfc ended in the remains
of the yelfc-sa^. The large intentine was greatiy distended
and ended in a blind attachment to the coccyx, thns
lying in front of the bladder, which was ahove and behind
the pubes. The anue was imperforate, and consisted of
a dimple an eighth of an inuh deep in the normal position.
From this dimpio on its deeper surface was prolonged a
fibrous cord which ended in a masa of fihrona tissue between
the ischia, where it met the termination of the spinal cord.
The liver was normal in appenrance, bat slightly altered
in shape. The spleen was at the right side of the abdo-
men.
OiRCt3LATOBy Stbtem. — The heart was entirely nutBide
the thorax owing to thodefonnity of the latter, as will be
descnbed. The foramen ovale was open, and the soptum
vontriculornm incomplete at its upper part As the entire
ORvity of the thorax waa tonstitnted by wlmt ought to
h&ve been only the right half, the vertebi-al colnnin lying
in the left division, the aorta descended on the right side
of the spine, having cnrvod over to the left and backwards
in the normal manner. The left vagua and recurrent
laryngeal nerves bore their usual relations to its arch.
The BHbseqnent course of the aorta was peculiar, and will
hest be nuderatood hy referring to the dia,gram (Fig. 2).
Juat below the level o£ the liver a large branch was
given off, from which sprang the renal artery (3), the
superior mcBcnteric (4), the right and loft siipraronals
(5 and 6), ii-nd the hepatic (7) in the order mentioned ;
tht' renal arising very close to the aorta. Almost opposite
this largo trunk the left common iliac {2) came off, and
here it must be considered the aorta divided. This
common iliac immediately crossed the bodies of the verte-
hne (Ijaee of the sacrum), sent a few branches to the
parts in the left iliac foKHii, and was continned aa the
femoral. The rest of the aorta, or more properly the right
common iliac artery went on. Laming now to the right, to
HBTHOfLEIlONj ECTOPIA VIgCKKUU, KTC.
205
become the one ambilical iirtery, previously giyingoff tbe
right femora] deep dowu in the pylvia, and an artery to
eacb v&a deferens, with soma amatl vesical and other
.branches. The umbilical artery ran above the level of
the kidney to the amaion formini^ the right half of tlie
abdominal wall, on the edge of which it ended, and where
V
r^/
10
fi
Fte. 2. — Sclieme of aortic bnuoli«i. 1. Aorta. %■ Left. iLi^ic
art*Tj'. n. Hcnal artery. 4. Sujwrloc inciipnteric nrler,\ .
& nnil 6. (tight nnd loft ftiitirfirsnril nrleriM. 7- Hppntiit
urUry. 8. Kighe iliac uriety. 0 •iid 10. BigliE and left
dcftrrcntinl ttrlnriw. 11. UnibilimI entity,
it donbtlftRs at once entered the placenta. The xmni
followed much the Baine courae, the only fresh pecu-
liarity being that the utnbilical vein, inxtcad of runntnff
along the under surface of the liver^ ran to the right of
that organ, sent a few branches to it, end joined the vena
cava inferior just above it.
Respibatokv Systbii. — ^The hings contained no air,and uo
part of these organs, excepting a small portiou of the right,
lay in the thorax. The luryux and traclieu. wcro nonnal.
The thytnun gland, a part of the right lung, tbe ocsophsgue,
and the aorta occupied all the existing thoracic cavity.
Mpscdlar Systkk. — Tlit- muscles of the back were very
ill-developed on Che left side, tbe spine running close to
the left, edge of the thorax. The glutsei mBximi were very
small, and, in the absence of a sacnim in iti* usual position,
TOL. xxxii. 15
2U6
DISSBOTiOH OS A FU;i'DS, tBS SVSISCX OX
arose mostly from a tendinous median septum, but also
from the first and second lumbar arches. The left rectus
abdominis mnsole only was present. The muBcleft of the
legs and right arm were well developed, tut in the left
several were missing, owing to the absence of the ulna.
Neevods System. — Srain and head normal. The spinal
em-d was uot-mal in appearance, but ended opposite tlio
budy of the fifth Iiimbur yertebrte. The Slum termiiiale
ran back, leaving the body oE the sacrum, to the mass
of fi.brouH tissue between the iachin,.
Skeleton. — Vertebral Column : There was a spina bifida
occulta, involving the two lowest lumbar and all the sacral
vertebrffi in suoh a way that the arches oE al! those ver-
,4a<l
:ii
'^:
v/vfi
VlB.S. — Sliawinj^flirnn^cmtnt orUminm ami rilx, ipi u* tiiAdn,
npproiitnatian «f iachlal tnlifriMitiix, niiil flecion uf ajunr,
Doltei! liiic=(.-nittinunti()it uf Bti»(itn and coccyx.
tfbriB were crowded together above, leaving the pn.sterior
aspect of the bodies exposed below. Above this mass of
arches, which consisted o£ n solid plate of bone and car-
tilage, the first throe lumbar vertobraj had only half-duve-
SBTEOrt-SJCIOK, BCTOPIA TTaCBRDM, ITC.
207
loped latiiiDee, the ends of which were able to comfi in
contact to complete the spinel canal owing to the retro-
flcsiiiu.
The right pedicle and lamina of tho twelfth dorsal verte-
bra were absent. The Hght half of the body of the aauae
Tcrtobra was ahsont, vanishing off like the point of a
wedge from tho left aide. In tho body of the ninth dorsal,
the right aide was cadevaloped ; bat the arch vta& com-
plete.
The left eleventh and twelfth laminie corresponded ^vith
and met the right eleventh ; the end of the tenth right
did not meet the tenth left, biit lay just below it ; and next
above the tenth left came tlie tip of the ninth right, and
then that of the ninth left. There was tlrna a displace-
meut downwards of the ninth and tenth right liimimtj with
reference to the corresponding left larainai, giving a pecnliar
plaited appeni-auco to this part of the spine?. Above this,
and up to ihe fourth incln8ivt>, the ends of thelamiure lay
opposite each other. The thirdj second, and first dorsal
vertebrae hml the same peculiar arrangement hr the uiuth
and tenth, the right laminte Iving below the left.
Tlic cervical vertebrie and skull were normal.
The ttemvm was .short imd very broad, but not fissiirnd.
There wore only eleven complete ribs on the right side.
The tenth and eleventh wore fused into a broad plate »t
their outer extpcmitiei?, and the twelfth was represented
by a spur-like process on tho lower bonlor of this plate.
The left ribs were closely applied to the bodies of tho
Tertebne, winding round them (Fig. 4),
The whole ><pinal colnnin curved backwards and to the
right, to the extent shown in the figures, and ronghly round
R radins of about 2J inches. The curve was ncute in the
lumbar region, where the hiatus in the roof of the canal
at the level of the first three lumbar vertebrae occuri'ed.
The pehHs was much diatoitcd, nnd the dir^tortion was
duo more to the relative poeition of the bones to one
another than to malformation of individual bones. The
true pelvis was prnctically reduced to a more irregular
208
mssBcnos of i fottcb, the bifajbot or
fissore between the pabic and ischial bones on eacli side,
as the tubera ischii were almost in contact (Pig. 3) and the
pubic sjmphysis cloeed. The ilia -were so placed that the
uoraisiUy anterior internal aspect looked slightly ont-
f^
jup
Pro. 4.— Showing ilinpe of iliorBX. fleKion of tpiuv, vvenion of
tllH, Had jMnUiim of coccyx.
wardB (Fig. 4), and their surfaces were convex anteriorly.
When, h"wever, tlic tubera ischii wore separated and put
in their normal position, nnd the innominate bones beat
fonvanls on the t^acrum, tlio pelvis did not appear much
distorted. In the original position the acetabiila lookotl ■
almost directly backwards. The whole pelvis faced con-
siderably to the left, this being due pnrtly to the flexion
of the spine in that diiertion and pnrtly to the pelvic dis-
tortion. The fi'nioral H.rticula.tioiis were normal. The left
OB initominatimi was a trifle smaller iu every way than the
right, espocially in the length of the iliac crest. The right
crest mensnved 1^ in., the left IJ in, The loft anterior
■Riiperior f;pinc was bont bncUwnrda more than the right,
and lay more in a vorlical line over the tuber iachii than
on tlie rii^ht sido. Tht left ala of the Hacrrnm was rudi-
mentary, the right being normal.
JjKKi v\iiM, — The uliia was absent. Articulated to the
rndiits was a cnrpus of three bones, presumably scaphoid,
trapezium, and trapezoid ; the two latter each boro a
digit.
RBTBOrLEXlON, IlcrOPU T18CKRDH, KTC.
209
I have doacribed thia coUeetion of deBormiticB rathyr
fully, as it aeyma to rae tn a great extent to carry its his-
tory and mode of production written on its features. Ab
to its caut;e there are many suggestive poinlii. In their
paper publisliied in vol. xxvi of the Society's ' Transactions,'
Dra, MattLewB Duncan and Hnrry have fully disctissed
tlie subject of retroflexion of the foetus. They explain
this deformity in cases wliere there is no cord, as in the
preaoat iustauce thus : — " The abdomen oE the foetue is
firmly held by its attachment to the placenta in the e^g-
Hhapcd cavity of the nterus. Tho two cuds of the ftt'tal
m&68j cephalic and pelvic, are pushed buckwards for want
of room, and flt-xion is on the fixed point, namely, tho
placenta forming the anterior abdominal fu-'lJil wall.
When the placenta is median as regards the fcetus, tho
retroftexiow is direct — tliat is, without lateroflcxion. On
the other Land, the further the attachment of the placenta
is from the median line the gi'eater vrill bo the lattro-
£exiOD."
V
'A,
t
wRa>
PiQ. 3.— Attitnilo of fatUB im utnv. Ifotteil line reprcKnU
aUrinc wall.
This expUnatioQ will, I think, apply to tho prosont caso.
In fact it ia at once auggested on looking at the specimen
in the position shown in Fig. 'i ; also in tho skeleton. Fig. 4.
Uere it ia seen that the fistus retain.*) the curve which the
inner surface of the uterus f^avo to it, and ahows well the
effects of pressnru on the side which was iigainst the utei-iuo
210
DisBXcnoH or & totos, tbb auBiBCT or
wall, namely the left. The left, no doubt, was against the
uterine wall, or rather against the placenta, because a
little of the right side of the abdomen was covered with a
flap of skin and amnion, and the IcFt uncovered, Unfor*
tuuately, the placenta was detachitd from thefcetus during
Inboar, and was not preserved. lu addition to the absence
of conl, there was another factor, the presence of a twin
in the uterus, t«nding to keep the deformed foetus against
the wall ; though the effect of this last could not hare
been of any importance, as the pressare-effectB were all on
the nterine side.
These pressnre-effecta were ■. — ( 1 ) Flattening of the thorar
backwards and to the right, obliterating the left half of
that cavity and causing the left ribs to be closely wound
round the vertebrnl column. (2) Incomplete develop-
ment of the left arm, and all the muscles of that side of
the trunk. (3) Flexion of the spiue at the lumbar region
to the right and backwards. (4) Flexion of the whole
pelvisin the same direction. (5) Extension of the thighs.
(6) Rotation outwards of the knees and eversion of the feet,
the laet being the easiest way in which the feet could
follow the surface of the uterue.
Internally, the abuormalittes were nearly all on the left
sideband could be accouuted fur by prestiure arising during
the middle months, though perhaps the complete absence
of the left kidney and ureter, and (?) of the left nmbilical
artery could not admit of the same explanation. Those
abnormalities were: — (1) Absence of the left umbilical
artery, posaibty due to compression of the left iliac against
the bodies of the vertebra) when it crossed them. It wiU
be remembered that the aorta lay to the right of the spine.
(2) Transference of the spleen to the right side. (3) Small
»iKB of the left suprarenal body. (4) Expression of the
left lung and collapse of the left side of the thorax.
[5) Small size of the left innominate bone. ((>} Absence
of all aortic branches except the iliac on the left aide,
the loft supnirenal arising from a branch on the right aide.
The artery to the left Tas deferens roee from the right iliac.
BETBOPIiBXION, ECTOPIA VI90BRTIM, BTO.
21]
The kidney and the abnormality of tlie gut will bo
cousidcred later on.
Tho rectum, BUpposiog it to have been ncrrma.!, would
have been unable to jota the anal involution, for tho site
of the anas was earned far buck with the pelvis. Tho
testicles were prevented from deecendin^ by the nbsence
of inguinal canals, and by the great disturbance in the
proHsure of tho abdominal walls and the relations of the
riscera,
Ahlfeld,Forster,Vrolik,Bud Ilouel mention and comment
upon the association of retroilexion and ectopia viscerum,
and they all have conjectural hypotheaca on the subject.
The conflicting opinions and theories of these four aothori-
tiea require some consideration.
Ahlfeld (' Die Misabild. des Menachen,' PL 2, p. 201)
believes that the vitelline duct ma,y persist and remain
firmly attached to the intestine. Then, in case of sudden
incrcfLSo of amniotic fluid, the duct drags on the coil of
glib found in the bs3e of the cord up to the third month,
prevents its recession into the abdomen, and may gradu-
ally drag out the whole abdominal contents. This traction
acts through the mesentery on the spine, dragging it for-
wards and caiiaiug retruflesion.
Forster (' Mis«bild. d. Mensch.,' p. 110) says that it is
duo to two causes. (1) The absonco of abdominal wall
and abdominal contents leaves the spine unsupported in
frontj nnd it therefore bulges forwarda. (2) The weight
of tho same contents tends to drag the vertebrse forward
olao.
Vrolik ('Tab. ad UluBtr. embryogen.,' pi. 21 and 22)
oonsidem that the association is due to the last-mentioned
cause.
liouel ('Soc. de Biolog.,' 1858, iv, p. 55) rcvorsca the
order of causation. Ue is of opinion that tho bunding
bnckvrards of tho trunk so dimiuiithos tho thoracic and
abdominal cavities that they arc unable to hold their
Dfttaral contoDta. He considers the shortness of the cord
to be the primary fault.
212
DISSECTION 07 A F(ETC8, TEE BCflJECT O?
(The opinions of the Inst two unthoi'Lties are quoted
from Duncan and Hui-ry's paper.)
It is impoiisiblB to accept the gnggestioiiB ot Ahlfeld,
PoTster, and Vrolik. They produce no facts to prove that
such forces as tbey mention are in action. These alleged
forcea are dragging of the viscera forwards by biieir weight
or by the vitelline duct, and the tendency of the spine to
bulge forw&rda if the abdominnt organs be not applied to
it. Supposing that part of tbe intestine were dragged
forward to any oxtentj it is the mesentery which would
give way, or the intestine would be ruptured (as, it is
said, sometimes occurs) hefore the hastnal concavity of
the embryo coidd be inverted.
The matter is different if the fau)t lie in the allantois,
assuming this to be an organ projected from the hind gut,
as is usually taught. Tfaia has a fixed attachment to the
solid parts at the tail-end of the embryo. If the skeleton
of the present esnrople be cxamiTied, it will bo seen that
the saorum and ooccyx have kept well to the front, and
that the yielding has taken place mainly at the sacro-iliao
joint.
Against Houol'ti hypothesis the case of retroflexion
caused by amniotic taudB, figured and described in the
aforesaid paper, is evidence, there being no protrusion of
viscera.
lu the specimen ot retroflexion in a tenth-week embryo
described by Mr. Lockwood (' Trans. Obst. Soc.,' vol.
xxis), there is no protruaion. The deformity in this laab
caao is due to absence of medulla spinalis and consequent
restricted development of the dorsal side o£ the embryo,
It aeetUB, thereforcj that retroflexion and ectopia may
occur independently, though they are as a rale aesociated.
To some independent cause, as in the above cases, must
bo attributed examples of retroflexion when the cord is
sufficiently long.
In the present specimen there was probably a common
cause, and the case would be most simply explained by
some deficiency in development of the hind gut and its
CETROyLKXlON, BCTOrU TieCERUM, BTC.
313
processes. Tliis, it will be remembered, was so far abnorni»I
that tlie rectum ended bliadly, beiug atta'ched to tlm tip
of the coccyx.
In A paper on the derelopment of some parta of the
vascular system (" Early Development of Paricardinm,
Diaphragm, and Great Veins," ' Phil. Trans.,* vol. olxxix
[1888], B., p. 3t>5) Mr. Lockwood has showu that the
formation of the umbilicnt veins, at nil events^ is inde-
pendent of the altantois. He biclidves that the latter
structure in rabbits, and pi-obably la man, does not grow,
as in the chick, in the shape ot a vascular protrusion from
the hiud-gut, but that the extension of the hind gal inti}
the fcetal pUceuta is a process of lucluaion and not pro-
LrusLOD. According to him, the fcetal placenta is formed out
of a portion of the caudal end of the embryo which never
becomes detached from the endometrium. The cord is
then developed by lengthening of the bridge of tiHsue,
vesBoiB, part of included portions of hind gut, &o.
If this method of development of the placenta and cord
be accepted, it is easy to understand how the abdominal
surface of the foetus was kept iu close contact with the
utoruH. The stroctures forming the cord failed to develop
to their unnal extent, and thus prevented the closure of
the abdomen. The right umbilical artery only could be
found, the absence of the left being due either to original
failure to develop, or to absorption from pressure on tho
loft side. The right kidney was hydronephrotio, probably
through obtjtnictioii to outflow of the nrine. Tho left
kidney and ureter were absent, having perhaps been ab>
sorbed owing to completo obstniction at the allantoic
(bladder} end of the ureter at a very early period. Mr.
Bland Sutton has described a fcetua (' Trans. Path. Soc./
1888) in which there were neveral malformations of the
alimentary tract, assuciuted, as they frequently arc, with
spiuu bifida. Uu, in common with other obHervcrH, iti of
opinion that the spinal cord is to be regarded as a highly
di£foreutiated section of the priiuitivo alimentary tract, and
that the almost coostaut asttociation of defoctti iu the two
214
UtSSEOTION OF A FOCrLie, TIIS SUBJECT OF
B^steniB is thus explained. (See abo Prof. Hamilton's
receiit address to tbe Philoeophical Ingtitiitioii of Edio-
burgli ou " The Deyelopcaent of the Nervous System.")
The present Case was the subject of spina biSda occulta
in the lumbar and sacral regioos, and of failure of uoion
in several other vertebral arches, as doBCribed. There
was also a cerd Hxt&nding from thti dimple representing
the aauB to a mass of tibroue tiBsue between the iscliiaj iu
which uiass the Bpinal cord also ended. It is therefore
possible that the origin of the spinal intLlforniation had
an intimate cioniicction with the origin of those of the
alimentary tract. On the other hand, in this particular
caao, as the spina bifida occurred at the point of flexion,
it might have been due to defective development of the
arohes from their being vertically compressed owing to
the concavity at this point, where a meningocele probably
formed. This seems more likely from the appearanee of
the upper bonndsry of the hiatus, where there wan a
Bolid tunnel formed of impacted archea, the mass of fibrous
tisiiue between the ischia being possibly the remains of the
meningocele euc.
It might further be said that the spina hilida was an
expression of an abnormality iu the epiual cord which gave
riuu to the imperfect left arm and the talipes. Against
this theory is the fact that the spinal cord showed no sign
of cystic dilatation at nuy part, and was quite normal at
the «plit, which waa therefore due almost certainly to
meningocele and not mytiocole. The former is a com-
moner cause of this deformity than the latter.
The displacement on one another of oppoBite halvoH of
the vertebral arches higher up was doubtless due to the
flexion.
The fcetua described by Mr. Uodges at the last December
meeting of the Society displayed deformities similar to
thoi*e which may be seen in the present specimen. The
dissection of that fa-tua would liavc proved most instruc-
tive in connection with the subject of this paper. Mr.
Hodges kindly tried to obtain it for mc, but was, unfor-
SET&OFL&StOii
215
tunatoly, unsuccessful. In addition to other malforma-
tions, the foDtiis was, it will be romomliored, A.tiQncep?ialic.
Conclimtms. — The following' coiiclusiuiiji are offered :
Retroflexion and ectopia viscerum, although as a rule
assaciutod, may occur inJepeudeutly. Tliey may, iliere-
foro, be associated and yet not hare a common caiiSK.
The only apparent manner in wticli a common cauns
could act is that described by Duncan and Hurry, namely,
by shortening or absence of the umbilical cord, the abdo-
minal snrface of the foetus being thereby held fast to tho
uterine wall nnd placenta. The latter by its close appli-
cation prevents closure of the abdomen, keeping apart the
oontripetally growing edges of the abdominal walls.
This common cause is failure in development of the
hinder part of tho gut and its procesaes.
To apply this to the present case, the coutbo of events
wag probably as foUowe :
I, Imperfect derelopment of the hinder pait of thegiit>
aud therefore of the allantoic, reaalting in (a) absence of
tbo umbilical cord, and (F) of one of the vessels (nmbilical
arteries) normally projected on tho allantois; [b] interfer-
ence with the outflow of urino, possibly at the allantoic
end of the urotoi's, producing right hydronephrosis and
ftbsenceof tho left kidney aud ureter. Resnltiug from (a),
olo»e application of fcctiis to placenta and uterine wall :
causing (re) Hexioa with its effocts on tho epine (menin-
gocele and spina hitidn occulta] ut the point of flexion ;
Jh) pressure effects on the rest of the body ; (c) failure of
abdominal wall to close.
Mr. Albam Doran ainoerifly hoped that Fellows of the^ciety
would imitate- 0r. Dalfiu and hriog forward carvfulty prepared
papers on spfciitl cuxes of mouHtrositj. or, Wtter still, on noma
eDtire cIm-i of mousttT. Tho Soeiotjf ufTL'red particular adran-
tageti fur the dvmoutitraliou and pubhcatioa of mattriiil uf thi«
kind which othorwisi' would be lost, for oheervers cuuld not he
«ipected to pubhiih toratole^cnl eisays at thmir uwu vxiwuse.
TcratologY.a very iwportantbnt iu certain rcKpi?ct« unproblable
science, had been Inft too much to the French and uermans.
The Society wait in a position to wipe awn,y that reproach.
216
A CASE OP SPURIOUS PREGNANCY SIMU-
LATING ECTOPIC GESTATION.
By E. SiNciJLiK Stevenson, F.R.C.S.E., &c.,
KOKUKBOSCH, CJFB TOWS.
( Ki^cuvcd November 2l8(, l&gO.)
Mks. S — , ujt^ed 24^ 3-pfvra, tLioe abortioiis, lufsfc child
boiii in April, 1888. A heinltUy, geuerallj briffht persoD,
and not in any way norrous nor hyst'erioal.
She ment^trnntud la>it in September, ]888, and from that
timo she conchided that ulie had btjconie pregnant. She
foH then as shu had iilwayH felt when in that condition on
previous occasions.
In January^ 18S0, she says that she had sevore pains
&iid a bloudy discharge, and thought that she wan going
to luiscnrry, but she got over this attack, and quickened
ub the expected time.
In April the movements oi the footus were distinct.
This statement was corroborated by her hnsband, atster,
and fi-ieijds who saw her. The abdomen was enlarged
and the breasta much developed.
In April labour began, and the patient sent for a mid-
wife. The pains continuiug for three days, a medical man
saw her. Towards the end of tlie third day slio piisaod
from the vagina what shti called a " piece of skin." The
medical miin present saw it, and instructed the nurse to
send it to his house, but hia order ivas neglected. His
itnpre»sinn at the time was that the case was extra-uberine
pregnancy.
The bearing-down pains passed away, and with them
the fa-tol movcoieuts gradually diminished. The next day
she had « profuse discharge, and Iho abduminni swellii^
ePDBIOCS PBBONAWCY 81MPLATIK0 aCTO?IC Q88TATI0N. 217
rapidlj disappeared. The breasts were secreting milk.
From tliat (la.te stie felb ill, linviug constant pains, nml
euflered from u imico-piiriileut dischurge.
At tbc end o£ Jul; I saw lier. She was then complain-
ing of weakness and paiu, aucl had shirering fits and night-
Rveats, Hep tsmperatuve whon taken was iiornaal. She
looked woi'u, bnt not ver^f ill, and was unable to walk or
stand withuut inuch pain.
External E.raminatinn. — In the right side there was a
swelling the size of a large fist, moveable, and changing its
place according to the position the patient occnpied. The
abdomen was generally tender.
Varfinal E^plitratuni. — Oa large and patulous, admitting
the index finger as far as the internal os, pointing untcriorly.
In the right fornix a soft mass could be plainly felt. The
nterus was retroverted and free from adhesions. The
uterus WR8 rapidly dilated and the cavity carefully exa-
mined.
The diagnosis of an interstitial gestation with rupture
at the fourth nionth into the broad ligament was made.
On account of hectic symptoms an operation was advised.
The patient was admitted into my privnte hospital. On
August l+th she was operated upon, and au ovarian cyst
of the left side was found and removed. Tlio Yiscera were
normal. The jMitient very soon recovered.
Remarks. — 1 think that 1 may bo excused this dia-
gnosis, r had boforo me a chain of evidence, the liulcti oE
which taken singly or collectively led me to give this
erroneous opinion.
All the symptoms of pregnancy, based on an experience
of six gestations, of which three came to full term, were
here present. Very clear signs of ectopic gestation wen-
lit hand, and finally these two clneses of symptoms wen-
complicated by a spurious laboar. The only explanation
that 1 can give of the above case is that some cause led
the patient to think that she was pregnant at the time
whon the tnmour was first noticed ; that the tumour grew
at a pace equal to that of s fcetus in normal gestation.
218 BFDEIODa 7BI1GNJIHCY SIUULATIHQ ECTOPIC GKBTATION.
and imagination would do tbe rest. At full term spurious
contraction took place and the thin-walled cyst burst.
At th« time of the operation I carefully, bat in rain,
looked for symptoms of previous rnplnre. One question I
should like to be answered by the Fellows of this Society.
May o cyst which has burst fill again and show no sign^
o£ former ruptiire> such as adhcsioua ttud Other inflam-
matory prodacts ?
Dr. SfiTTHEwa Dcscan, in rpsponae to tho qupstion in the
paper, said thnt kc had long ago publiehcd a case iu which au
o?ar>a.n cjst of larg* size was spoLtaiieously t-vacuated thi'ougb
the uterus. Subaequently, after refiUing, ovariotomy w<L8 per-
formed, and then no trace o£ counectiou between the cyatonia
and the tuhea or uterua could Ijl.' found. But he had seen flreii
more reniarbabie inetancea of repair of analogous kind. A
wonmu wailing for ovariotomy had a Urge perimetric mass high
behind the cervis uteri, ll burst aud discliarged pus and fieces
iu laryo quantity. Tho fingvreould easilv pass ihrongh tbe roof
of the vagina into the fracal abscess. It soon heiti^d, and iu lees
than three weeks after the healiug ovariotomy was performed
successfullji. At the operation search was made, but no trace oC
connection h4>(ween hoivel and vagina could Ive found; there
were no adhesioiia in the region of the vaginal roof.
Dr. HoEEocKS mentioned the case of one of his surgical col-
leagues wbieh he had examined. Just before the operation of
ovariotomy was undertaken tbe patient was seized with sudden
Eiiiu aud coDapsc. She rallied, and in a tew days the tumour
ad almost vniiished. Dr. Horroeka again examined, and felt
the collapsed cy*t, which had evidently ruptured, ponrins^ its
contents into tbe peritoneal cavity, frum which the fluid was
absorbed. In a few weeks the cyst refilled, abdominal section was
performed, and the tumour was removed. At the time of the
opentioa there was no evideuceof aoy recent peritonitis, neither
could there he fouud any scar upon the cyst-wall.
FEVEE IN CHILDBED.
Part I. — Gteneril Htoienk asd Antisepsis.
Hy Robert Boiall, M.B., B.C.CantJi.b., M.R.C.P.Lond.,
UimXVT OI13TIITR1C PHTSICIlli TO, AKD LKDTcmKR OK PBACttClL
UIDWIFEBT AT, TBB UlDDIiKSBX HOBFITAI..
(Ufrwirea December 10th, ISSa)
Abstract.
r. Thfi genoral fever-rate and neptlf rate of the Qev-prnl
Lyi'ig-iii Jlospital dnniig (/te last seven ymr» ; marked
deelvne.
In tliofiret part of tliie pappr Iht EaetnrB which litar uiiiversiiUjr
oil the »iil>jeot are alont> cuiiHuloroi] ; iinrticuluvs porlaiiiiiig to
individttal casea, such na the general couditioii of the patient and
tfai! cburaclcr oC the labour, ore itot incladed. In such an
extondoil series as that now presented, tliese items arv dis-
Irihiitetl with siich approach to uui formity «» to ryiidor the
otniaaiou a matter of little iniportauce.
A seriL-s ttC charts and tahlt-s arc rippfndod whicli deal vrilh
the 2762 puerperce who have been delivered iu the OeaeraJ
LyinR-in Hospitiil during n period of seven years, from July,
1882. to June, 1889, incluBiTe.
The figures upon wLich Charts I, II, aod UI are construiited
are given ia Table I. The readinga ai-e all taken from the base
liuo.
By thia mean$ it will be jtrcved —
(1) Tltal Ihe j)ri>jiortion of case* fij^fct«d with /ever ducUned
ra^dlt/ and t)wn beraiae tteady, but haa idnce dimini«hfd tlightly.
(2) That ihi» decline hat m the main vaulted from decrease in
andtanporary abolition of taaea affected witk ii2>iicKmia and pelvic
it\fiammittioa.
220
FBVER IN CUILUIIED.
(3) Thai in the febrilf^ catea both the duration anit /Ae height of
the f aver hnw. ttimiuUhed.
(4) That thete chan<ft.t are ideniioal in point of time with etrtain
ekangea effected in [he hospital service.
Cliart I yive« llit- toul iiimiljev of ]mtieut« admitted, the
number of raees in which the tciuperature rose ahuve 100" P.,
the uumber of patients who were affected with aepticiemia and
polvic inflamiiia,tion, and th& total average daily amount of
furei' from iil) cuuaos (L'stiiniLtCid in iacroiuents above 100° F.)
fortach month.
This thaws : an increase tn ihe number of admitiiont, a decreaaa
in the numhfr of ffWi}^ easet and jiarJieulafly of teptie catft,
and a diminution in the amount cf Jeter noi only relative but
tthiolute.
But OB the number of patients iidmitkHl mouth b>- mouth
Tftiive so conaider&blv as to render eouipariaon o£ one month
• with another tt mutter of difllmiUj, separate chiirts based on
pereentagea ant also ap]>ended,
Chan n 18 divided into four pivrta ;
The Jirel diviaion gives the percentage of palieuts in whom
the temperature rose abi>ve 100° F. aud the percentage of
patients who were affpcted with septieajiiiia and jxtlvic itiflrini-
nmtioD.
Thit thoics : that of the lehole number of patients dcUftred in the
hotpHitl h'fore and after May, 188i, n Jrop occurred from S.! per
cent, to \M-{\ per cent, in the cust-t foJioivrd hy fever, and /root
40 per cent, to 2"5 per cent, in the ensea follotaed hij teptie fever ;
and, further, tnJiaates an improvement in both reitpeela in tht
montht which immediately precede that dale.
Tit! fecund division gives llie average daily purcentage of
patients in hospital with pyrexia imd with aepticieuiia and
pelvic inflamumtifln.
It will be observed that this diviHion o£ the Rhart takes into
account both the proportion of febrile to iion-febrile cases and
the duration o£ the fover, and also the proportion of »eptic tfl
ll'>n-*Ciptic CIW09 and the diirntioii of thp fever with wbicb thcv
were auooiated.
Thiaihotct; in comparing all the cain lefore and after Mau,
1SS4, a drop from 39 jfcc cent, to 8 per cent, in the dail\/ ^ropor*
FKTKR m CHlliOBID.
lion qf ciMCK (It hospital with fever, and from 27 per ecitt. to
VG per cent, with itfptif fevet- ; and, further, indicatt>s an itn-
proemnent in both re»peott in fh& months which ivimeitialely
precede that date.
Tbe iMrd divisioii gives the average duration of the Sever in
days.
Thii akoips : IB a comparison of at! the fehrilf oa»f» before and
aprr Mny. 1884, that the duration of tkn fecer was rediicedfrom
7-7 to 8 dayg, together with tome improeevwnt in (kit rerpeet also
in the months which immediately precede that date.
The/owrtA rftvi>w« gives the avcmge height of tho fover in
degrwB above 100° F.
Tkit thoicx: an avitra^e reduction in the hciijht of the tempe-
rature dating from Maif, ISH4, of very nearly 1" F., bat no
appreciable improvement in iftia retpeot in the monlhe which
immediately precede that date.
Considered as a, whole. Chart II proves —
That not oiiljj has the proportion of febrile to iion-fchrile cases
dimiaithed, but aUo the proportiun of sepdc to iton-trptic casee
has at the tame time vtitl more markciUy dimtuished, that far
months together such iwint^Ji have entirely dixappeared, and that
limultaneojuly the duration of the fever hat been shortened and
itt height diminished.
Chiift III eipresACH these reHults in a condensed form.
It gives in ciitliii-? ouly (white on black ground a»d vice
vend) the average atnount of p^Toiia from nil caiiS4.ii pt>r
pnti«nt (in dava X dogrcos iibove 100° F.). It will liu ob-
Herved thut. being the product of the tirst, third, and fourth
dirisiunH of the pi'ccoding chart reduced to unity, it UikL-H
into account not only the proportion of febrile to non-fcbril©
casuii and the duration of the fo*«r. but also the height of
the temperature; and therefore, a* an index of the condition
of the hospitAl for cacii month, is not to be 8iir|>a6sed. But ws
it often bap})en<'d th£it paticDta admitted towards thn end ui
oae month had little or no fever until the following mooth, and.
that when the attack vax proluiiged the fev«r was continued
into the month following adntianion and even later, this line
only rcprpsents approximately the f«ver-rato for each paticob
admitted during the mouth to which it refers. It hu there-
VOL. xxiii. 16
S22
FiyKE Df CUdDBBD.
fore been j>l(iced iinilor tbc betwliiig of " Approxaiude fevsr*
rate,"
The True fever-raie. i. e. Ilie average ami>imt. of iiyrexia from
all causes (in davs X degieeft above 100° P.). for eacli piitifnt
admitted duriu^ each mouth is ^ireu.
TAis thoiee : that eaeh patient admitted avernged ns much as
17 degrees iff fever during tkti jmerptrium before May, ISSJi, but
onitf 1 ileifrcK after that date ; and, further, that the amount tost
eoMiderablt/ redttccd in tha months whinh immediately prtmde thai
dale.
It may bo noted that the Tr«s and Approxiviale ftwr-rcUtt
T«iy nearly coincide when the cases of severe and prolonged
illness are few.
TLe sepivs rate, i.e. the average amount of pyrexia due to
Beptictomift and pelvic inflanimiition. (in days X degrees above
100" F.), for eaeli piitient admittitd during each mouth is aUo
given.
Thit ghomt : (hat each pemoti admif/rd averagrd n« much as
13 d^ifrces offtferfrom septicixntia and pelvic in-jlammaiioii alone
dufiny Ihit puerperiun before May, 1884, hut /«« than half a
deyree after that dale, the amount beiny often reduced to zero of
to a fraction of n dryroe for montht foyether ; and, further, that
the amount wh^ appreciably red-need in the monthi which immS'
diately precede that date.
This ehart further demonstrateB —
(1) That the decline in the general feuwr-rate has in the main '
retaltedjrom decline in the septic rate.
(2) That though occasional alight rises have occurred during
tie last fitie year f, the general tendency has hern towards improve*
meni not only in the general fever-rate, but aho in Ike septic rate,
and that when the general feccr-rate has riten it has in the main
resulted from increage in the septic clement.
1 pROrosR On the present occnsion to cnet my glance
bnckwardet from the erainence of the General Lyiug-ia
Hospitnl, orer the table-land of the puerperal state, and
would invite you to anrvey with me the subjeot of fever in
childbt^d by means of a eeries of thermometric observations
which have been carried on continuously during the last
FBVSB IN CHILDrZD.
223
acTen years, and which, for purposes of couiparison, are now
presented iu n collective form for encU mouth (pp. 235a,
B, c, D).
Tbts subject ie ono which has ongagod inucb attention,
and deservedly 80. Yet several points cumiectt^d with it
still remain open to debate. It is a. suhject ou which
suificient has beeu writtcu to t'orrn a library in itself, but
I ehall not attempt to catalog'ae ihs works which bear
upon it.
Id 1884 Dr. E. S. Tait reviewed the subject from the
eame position ns that upon which I now stand, having in
the latter half of 1882 recorded a series of borings through
the diiferent Btrata of the puerperium. In a valuable
paper read befora the Society, and entitled "Some Observe-
tioDS on Puerperal Temperatures," he drew attention to
Tftrious fftctors which are operative iu the producliou of
fever in childbed, and more especially to the iuOueuco of
traunitttiain/of forceps deliveiy, of lutra-utcrinu uianipula*
tions, and of cmotioual display, Siucc* that time, however,
the nature of the ground, aii it is my preseot iuteution to
bkow, haa altered considerably — solnuch so, indeed, that
1 trust it will soon be possible to clear up some at least of
tbo ambiguouB points connected with that part of the
queetiou.
In the Brst part of the present paper it is my intention to
deal with conditicua which boar universally ou the suhject,
rather than with ihu peculiarities of individual cases — to
take a broad survey rather than make s minute innpoclion.
For though it is qnite true that thecaHca might bo divided
up into particular classea, after the method adopted by Dr.
Tait, each of which nuay be shown to posseee its own parti-
calar bearing on the incidence of fever in childbed, in such
an extended series a^ thut now presented theso classes
become broken up and distributed with such approach to
uniformity as to render the omission a matter of little
importance. In a subsequeut part of Iho paper I hopet«
show the bearing of auch particular clasaoa on the same
subject.
224
niTKB IB CHILDBBD.
I propose, in the first place, to present a critical csaraU
nation into the state of the hospital vith the aid of the
appended tables and charts ; in the second, to recite the
menns by which the present sstisfartory state of the insti-
tation has been attained and is Htilt maintained ; thirdly,
to relate sach accidental espenences, id addition to the
alterations purposely introdnced into the service, as m»y
have affected the condition of the hospital ; and finally,
to snggest the lesBona to be derived from these varioog
oonsiderationB.
It may, however, be advantageoQS if in this place, and
before proceeding to discustt the different sections of the
paper in detail, I briefly review the histoir of the hospital
during the last few years.
In the years which preceded the routine employment of
anti&epttcs the amount of illness, and especially of septic
illness, mnst have been very grave, for the death-rate (the
only available gnide to the condition of the hospital at that
time) was invariably high, bet presented oreat variations
and often indicated an appalling mortality.
Then the antiseptic regime dawned, carbolic acid and
Condy's fluid wore regularly employed. Under this
regime the death-rate declined considerably, and on the
whole remained steadier. Cases of illue&s and especially
of septic illness were, however, always present to a {greater
IX lees degree, hut varied within wide limits, both as
regards freqnoncy and severity.
During the last few months of this carbolic and Condy
era a steady and appreciable improvement took place, and
in a marked degree with regard to the cnsi's of b septic
oatnre. This wdr dne in part to the improved method
of dealing with the antiseptic agents and to the meaas
taken to prevent their mutual destruction, and in part to
A more systematic attention to points of general hygiene,
particularly as regards the midwives and nnrses.
When subsequently carbolic and Condy were replaced
by sublimate a farther improvement was efEectcd, and
acpticiemia disappeared entirely, at any late for a tima
yETCR rs CFtLDBED.
225
[tlie ioetanoes of its recurrence being few and, as a rtitc,
far betweou and of slight iiiteiisity). The death-rate fell
in a remarkable degree, and from tbat date until the
present time the instaaces of illness have, generally speak-
ing, been slight and unimporta-iit, and in great piirt of
an accidental character, whereas septicemia haa figured
rarely.
Nevertheless, during tlie sublimate era tbreo oases h&Ta
died from the effects of septic infection ; one in the short
period during which donche-solutions of weak Gublimate
were employed, and tho remaining two jn another short
interval, during which the snblimate doucte waa replaced
by salufer. During this period also the other instances of
illness suffered appreciable increase.
Several examples of the introduction of Kjmotic poison
hare occurred, both during the time that fepticietnia was
still rampant and nlso since it has been practically stamped
out. A siugio occurrence of erysipelas during the first
period was attended with a striking incrcaao of illnees in
other patients, which, if notabsolutel}- identieal with, wag
indietingnishnble from septiciemia in its clinical aspect.
Scarlet fever Mveral times occurred both before and after
the elimination of septicaemia, and wne attended during the
first period with a alight but siiggeative increase in illness
of a similar septic nature, but duritig the second was, as
alreadystatcd, productive of no appreciable ill-effcct beyond
giving rise to cases of a more or less typical scarlatinal
type. And finally, noithor typhoid fover nor measles, a
Mnglc instance of each of which occurred Vluring the first
period, seem tn have produced any sucU effect.
Individual instances of the injurious effect of foul air
were now and ag'ain observed, but since the winter 1882-3
no general increase in the amount or severity of illuesii
Las occurred during the winter months as compared with
the pnrauior.
These points will be considered in detail in the various
eeotioDfl of the paper. Part 1 will be devoted to the effect
of general hygiene and antiseptic precautions ; Part II
226
revRit m cmtDSKD.
to the influence of zymotic poisons and of atmospherie
changes.
The aceonipnnying charts estend over a period oF eevon
years, from July, 1882, to June, 1889, inolnaive. They
deal witb no less than 2762 puerperae who were dolivered
in the General Lying-in Hospital, under the care of Dr.
John Willioais, Dr. Champtieys, Dr. Herman, Dr. Culling-
worth, and myself,
Certain eectiona of this period I would mention in par-
ticular. The first of these compriseB the six iiiontha end-
ing December, 1S82, during which Dr. Tait carried out his
obaervations. The second extends from Septemher, 1883,
to December, 1884, inclusive, when, as houee pliysician,
nndor the direction of Dr. Johu Williams and Dr. Champ-
neySj I was euahled to make special tibser vat ions on the
course of the pnerperium. The condition of the hospital
at this time was treated of in some measure in ray com-
munication on " ScBrlntina during Pregnancy and in the
Puerperal State," in which the position of scarlatina as a
cause of fever in childbed was diacussed. The third and
fourth eectious cover the last six months of 1886 and 1887
respectively. These last I propose to utilize on a sub-
sequent occasion in considering move pftrtioularly the lesa
Bevei'o forms of fever in childbed.
Through the coiirteity of my late colleagues an<3 of my
successor I have been enabled to fill in the spaces be-
tween these sections, and to present uninterrupted charts
for the whole seven years.
The result is instructive as showing the great improve-
ment which }iaa taken place in the condition of the hospital
within this period. For daring the first eighteen months
the condition of the hospital generally may be described
as one of high and persistent fever, varying much in
amount, it ia true, but still persistent. Then came a period
of gradual but steady decline, extending over some six
months. Into the cause of this I shall euter presently.
May, 1884, marks an important epoch in the hospital's
history. At that iirac fas I took nccasion to point ontii
I'KVCR IN CDn,DRED.
227
speaking on Dr. Dakin's paper oa mercurial ism read before
this Society in 1886) a decided imp pavement occurred.
Since tbat time, with the exception of oocasional nligbt
relapses, a steady convalescent slate has been maintnined.
UTit'se relapses "will also call for special comment.
The figures upon which Charts I, II, and III are con-
etructed are presented in a tabular form for pnrpoaea of
reference (see Table I, p. 235l>]. Tlie rcadiogs arc all
calculated from the base tine.
By this meatin it will be proved —
(1 ) Tlutt the proportion of caBcs affected with fever do-
cltued mpidly, and then beeame steady, but has since
diminished slightly.
(2) That this decline has in the main resnlted from de-
creane in and temporary abolition of, cases affected with
septicaemia and pelvic inflamniatiion.
(3) That in the febrile cases hath the duration and the
height of the fever have diminished.
(4) That these changes are identical ia point of time
with ccrtftin changes effected in the hospital serTice.
Chart I (p. 23yA) deals ia the first place with the total
number of patieiits admitted (indicflted by a fine cou-
tinuouB line), and with the number of patients who suffeied
from pyrexia (indicated by a dotted line).
The close approximation of the dotted to the thin cnn>
tiniionii line during the first eighteen mnnlhs shows the
small number of patients who escaped pyrexia. The sub-
seqncnt separation of one line from the other indicates the
great improvement which afterwards occurred. Further,
the persistent rise in the fine continuous lino denotes tho
increasing number of patients admitted lo hospital since
the improvemeot took place.
In the next place lie number of patients who were
affected with Kepticaimia and pelvic inflammation is given
(indicated by a thick continuous line). This liae closely
coincides in its variations with the dotted line, declines
with it, and after the first eighteen months at times entirely
disappears.
228
rKVEK IN CmLDBED.
This shows the decrease in the niimbpr and ultiiiiate dis-
appearance, of septic cases, aouietimea for months together.
Lastly, the total average daily pyrexia! rise — th&t h to
say, the nuQiber of degrees of fever (estimated iii increments
above 100' F.)) for diatribution among all the patieiite iu
hospital — iaulso giveu (indicated by a broken Hue). This
line U found to follow the declension of the dotted curve,
and, while aoarly approaching Iho fine eontinaoOB line in
the early monthe, to separate from it very widely after-
wards.
This 8110178 a diminution id the amount of fever, not
only relative, but absolute.
Turning now to the figures given in the table (p. 235d),
and taking by way of example December, 1882, it is found
that twenty-Bi-t patients were admitted, of whom twenty -fivo
had fe^cr, — all but one — and tliat of this number eighteen
had fever from septicEemta and pelvic iudummation aloDO ;
nud that on au avcrago tliere was distributed among the
patients a massed daily nraoiint uf fever of close upon 19
degrees. Now, by way of comparison, take December,
lfi84. During tliis month thirty-five patients were ad-
mitted, of whom only four had a rise of temperature above
100° F., one being attributable to septicfemia or pelvic
inflammation, and the massed daily amount of fever dis^
tributed among them was little more than half a degree.
Such figures as theae tell a very sti-iking tale.
Briefly, then, Chart I shows an increase in the nnmber
of adraissiong, a deereasB in the number of febrile cases and
particularly of septic cases, end a dimiuutioa iu the
amoant of fever, not only relative, but abeolnte.
But, as will be gathered from the table, the number o£
patients admitted month by month presents snch consider-
able variation as to render comparison of one month with
another a matter of difHculty. Instead, thcpofore, of resting
conteut with the crude figures, I have constructed a sepa-
rate series of charts based on percentages.
Chart IX (p. 28ob) ia divided into four parts.
The p]RST DIVISION gives the percentage of patients in
TUVKR m CHTtiDBED.
229
which the ti?mperature roue above lOO" F., aud the per-
ccntnge of patients who were afifected with septicomift and
polric in flam dial iou.
In each case the tempemture was titben (by mouth)
thrtvughuat the patient's stay in hospital every four hours,
night BH well ob day nolesa she happened to be aslcep>
and any rise above I00° F. is reckoned as fever. And
whcrerer the line joining two consecutive observations
orosse.s nny section of the cliai-t above thia level, that
section ia inoluded in the fever category, as if observations
had been made coatinuoualy iu every part of that line.
I may tiike occBBion hero to point out that had the tbor-
mometer beau cinploycd lose assiduously u large proportion
of the pyrpiin cft<es would have been climinnted, whorcae,
nnder the plfin adopted, are iuelud^d all the slight trausi>
tory rises of temperature (to 100*2'' ov thei-eabout) which,
though indicated by the thermometer, are as a rule un-
attended by appreciable Bymptoijis of illness. TheRe,
indeed, form by far the larger portion of the pyrexia cases
which have come under obnervatiou during the last Bre
years dealt with iu the charts.
Unless this fact be taken into consideration, the im-
provement as indicated by the first division of Chart II
would bo greatly discounted. For it represonts the per-
oentage of puorperto who bad pyrexia without taking into
eon side ration wither the hoight or the duration of the fever,
and therefore are included all those Kligbt tranbitory rises
to which I have alluded.
But, even taken eh it standi, a marked improvement is
manifest.
For during the 6r8t eighteen months the number of
deliveries folluwcd by pyrexia generally exceeded 70 per
cent., and oftou ruochcd an high &a 96 per cent. Duritig
the first four months of 1884 the figures declined from
SI per cent, to 65 per cent. Then occurs a wmarkable
drop, and from that time onwards 50 per cent, ie i-arely
exceeded. In general terms it may he said tliat prior to
Hay, 1864>, 83 percent, of the patients confined had some
280
PEV'ICB IK OHILDBRD.
rise of tempemtiirc nbove lOO'^ F. duriug the ])uorperinm,
but tliflt after that date 40't> per cent, were similaply
affectfd — in otlier words, that ike uumber of laboars fol-
lowed by pyrexia was more tliau halved.
But, in addiiioii, ilie first division of Chart II gives the
percentage of patieuta who were affected with septicBOraia
and pelvic inilammation.
This ahowa that during the first eighteen uontha the
proportion of deliveries followed by fjepttcesmia and polvic
inflaraination, thongh varying ffreatlj, never fell below
22 per cent., and reached aa high as 69 per cent., but
during the first four months of 1884 declined from 31 per
ceist. to 10 per cent. Of the whole number of patients
delivered in the hospital before May, 1884, no leas than
40 per cent, were attacked with Beptica^uiia and pelvic
iiitliiiuTnation, compared with less than 2'5 per cent, after
that date.
And bere I may take occasion to mention that a certain
atnoiint of doubt necessarily attaches to the septic data,
owing to the diBicuUy in deciding as to the precise cauae
of the fever in aoine of the cases. But as this difficulty
occurred mainly in the early months, and applies chiefly
to cases of slight intensity — to cases of saprMmia,^!
have no doubt in my own mind that, even when allowance
is made for t.onte of the fever from other causes being
masked by Bepticteniia, and consequently included in that
category, the improvement under thie bend wns actually
rather greater than is shoi^T in the chart. It may alfio
be noted that all cases which presented signs of inflamma-
tion in tlie piclvis, wliaicrer vieiv may be held as to the
nature of swch in iiidividnsl instances, are tiicluded in the
septic category. At the same time I may add that no
doubt whatever attaches to the genernl-pyroxia data,
which are based on facts involving no diagnostic skill.
The 8KC0SD DIVI8I0S gives the average daily percentage
of patients in hospital with pyrexia, and with septicemia
and pelvic inflammation.
A momeot's reflection will show in what respect this
FETXB IN CBTID'BKD.
differs from the preceding divJBion. In tlie first division,
tlie percentage of patients wlio were affected with fever
iitull witii septic fever was alone represented ; but this,
representing, as it does, the nverage daily percentage of
pntients in hospital suffering from pyrexia, takes into
account not only the proportion of fehrilo to non-febrile
cases, and of septic to oon-Bcptic cases, but also the dura-
tion of the fever, And, as I shall presently show, simul-
taneously with the diminution in the number of fever
cases, the duration of the pyrexia in such cases ag were
afFeotttd with fever became considerably less. The net
resnit, therefore, as given in this division of the chart,
is correspondingly greater — the improvement which tm>k
place appears to Htill greater advantage.
On reference to the table [p. 2-3od), it will be seen that
during the first eighteen months the average daily nnmber
of patients in hospital suffering from fever generally ex-
ceeded yO per cent., and was often as high an 50 per cent, ;
that during the first four months of 1884 the oorrespondiiiig
fi Inures declined from 32 to 20 per cent., and that
subsequently 10 per cenl. was Beldoin exceeded. True,
the drop does not appear so striking, because some of
the patients admitted during April carry their days of
fever into the following month. Nevertheless the rapid
fall is suggestive.
lu general terms it may be said that prior to May,
1884, the daily number of pntients in hospital who were
affected with pyrexia was yO per cent., against 8 percent,
after that date ; or — to put the matter in another way.^
this date forms the boundary liae between an attack of
fever extending oveir more than a third, and a pyrexia!
attack lasting less than a twelfth part of each pAtient's
stay iti hospital.
Tbe improvcmont in this respect is emphasized by the
fact that, originally, more often than not it was found
necessary to keep the patient in hospital for some time
after the fortnight had expired, in some cases for perhaps
30, 40, or even as much as 50 days, too ill to be moved ;
282
niVIB Iir CBILDBET>.
bat now for & patient to receive her discharge at a later
dato than tlie fourteenth day has become quite the eicep-
ttoii. Moreover, in order to guard against the possiliility
of any illueaa bt'iug uvcrlookid, every patient on lenving
the hospital is provided with an addressed post-card to be
returned at the end of a month.
In this division of the chart, also, the average daily
percentRge of patients who were affacted witt septic fever
ia separately repreaeutod. The daily number of patients
in hospital auffeiiug from septic fever before May, 1884,
averaged 27 per cent, of the whole (the number varying
dnring the first eighteen months within lU per cent, on
either side of that amouut), agaJDst I'd per cent, after
that date, when the curve exceeded 10 per cent, in oue
montli only (and that happened iu May, 1884, from illness
coutvacted dmiug the previous month), and often for
months togcthei" remained at zero. In this respect also
the improvement is well marked at the beginning of 1884,
The THIRD DirtsiOH gives the average daration of the
fever ill days,
This i& calculated for the oases of febrile illness only,
not for the total nnmhor of patients. The shortened
dnration of tlie fever is here separately represented.
Before May, lSy4, cases of fever usuiilly per«isted for
at least five and often as much as ton days, but after that
date the average never exceeded five days, and as a rule
■was much below. Speaking in general terms, therefore, it
may be said that fever which originally persisted for at
least a week now ceased at the end of lliree days. In this
respect also some improvement is seen to have taken place
during the months which immediately precede the obovc-
nicntioned date.
But the proportion of febrile to non-febrile cases and
the duration of the fever aa yet have been alone taken
into account. It remains to consider the height of the
fever.
The FOURTH siYieiON gives the average daily rise of
temperature for each pyrexial patient.
ri^VKR IN CBIIDBKD.
2S3
Here, again, a corresponding improvomeTit is manifest,
tunouuting to a redaction of nearly 1" F, For daring the
months whicTi precede May, 1884, the fever ranged from
10-2° to 103°. bat after Hiat date rarely reached 102** ; and,
iu fact, declined from I02"n'' to I01'6*' P., aa givou by
tlic collective averages for eacb period. No appreoiablo
improvomfat ia this reepeot is observed daring the montha
Wfhicb immediately precede tha,t date.
Each division of Chart 11, theoj is seen to agree in
pointing to an improvement dating from May, 1884-; and,
farther, sbowfi that ibifl improvemout took place to soms
extent in the months which immediately precede that date.
Considered aa a whole, Chart II proves —
That not only has the propnrtion of fehrtle to non-febrile
cases diminished, but ali^o the jiroportion of septic to non-
septic caHcs ha» at the same time Mitt more markedly
ditniniahcd, and for months together such ca&os have en-
tirely disappeared ; and thot simultaneously the duration
of the fovcr has been shortoned and its height diintui&faed.
Chart III (p. 235c) expreBftes these results in a con-
dcnacd form.
By maltiplying together the percentage of labours fol-
lowed by pyrexia, the duration (in days), and the height
(in degrees above 100'' F.) of the fever, it is possible to
present a fairly correct index of the condition of the
hospital for each month throughout the seven yoare. Sy
moving llio decimal point two places to the loft the
average amount of pyrexia from all causos per patient is
derived. The figures thas obtained arc very inslroctive.
By this means the variations which occurred are presented
in an amalgamated form. For, being the prodnot of tKe
first, third, and fourth diviBions of the preceding chart
reduced to unity, it takes into account not only the pro-
portion of febrile to non-febrile cases and the duration of
the fflvcr, tut also the height of the tenipcrnturo, and
therefore, as au index of the condition of the honpital for
each month, is not to be surpiusKod. But as it often
buppeued that patients admitted towards the close of one
234
TEVBR IN CatLDBKD.
month had little or no fevRr ontil the following month,
and that when the attack was proloDged the fever was
continued into the month follovitig admission and even
later, this only represents approximately the fever- rate for
each patient admitted during the laouth to which it refers.
It has, therefore, been placed nnder the heading of
*' ArpsoxiuATK PBVBR-E4.TE." This IS represented in Chart
III in outline ou]y (white on black ground and black on
white ground).
The true ^kve&'Rate — that le to say, the average amount
of pyrexia from all causes (in days x degrees above
100° F.) — for ench patient admitted during each month is
given.
By referring to the t«ble [p. 235d), it will be seen that
during the first year and a half the amount of fever which
followed upon each labour presented considerable variation
month by month, but that tt was invariably great — the
lowest figure, as given by the true fever<rate, approaching
6 degrees, atid the highest number almost reaching 25
degrees. Then follows a noteworthy declension. Through-
out the last five years, with the exception o( occasional
elight relapses (in which, however, G degrees was once
only exceeded), a point varying but little on either side of
1 or 2 degrees has been fairly maintained. These figures,
when reduced to general teriaa, indicate that prior to May,
1884, each patient admitted passed through, on an average,
17 degrees of fever during the puerperium against 1 degree
after that date. This, by way of example, may be takoo
to mean that every labour was followed by tomporaturo
rising daily to 100°— 101° P. for seventeen days, of lOl**
— 102" for eight or nine days, of 103° — 104* for four days
or rather more, or by a similar amount of fever otherwise
distributed; but that after May, 1884, a slight rise of
100" — 101* F. occurred for one day only — trulya ranrvel-
lous difference.
It may be noted that, when the cases of sovcro and
prolonged UIdcss are few, the true and approximate fevor-
rates very nearly coincide.
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FEVJCR Ol CHILDBSP.
236
The BEPTic RATE — that is to say, the average amount of
pyrexia due to aepbicffimia and pelvic indatnmatioti (in
days X degrees above 100" F.) — for each patient admitted
daring each mouth is also given.
On referring to the table it will be seen that the septic
rale during the first eighteen mouths on one oocasiou
almost reached 23 de^gi-ees, and rarely fell below 10; that
it declined perceptibly at the beginning of 1^84, and after
May of that year rarely rose above 3 degrees, and was
often reduced to zero or to a fraction of a degree for months
al a time. In general tei'iiiH it may ho said that the
septic rate fell from 13 to leas than half a degree.
This chart further demonstrates —
(1) That the dfcliiie in the general fever-rate has in
the main resulted from docliue in the septic rate.
(2) That, though occasional slight rises have occurred
during the last Sve 3'enr3, the general tendency has been
towards improTement, not only in the general fever-rate,
bnt aUo in the septic rate ; and that when the general
fever-rate bns risen, it has in the main resulted from
incrense in the septic element.
Three out of the four propositions set down at the out-
set hare now been considered in detail (see p. 227 nufra).
Before proceeding to describe the service of the hospital
and the changes which have been effected in it, it will be
advisuble to inquire more particularly into Hie nature of the
illness prevailing. This will occupy the followmg aectioa.
2S4
VEVER IN CBILDUED.
11. The death-rate and the nature of the iltnef^n prevailing j
decrease in, and iemporarjf abolition of septic cages.
(RewiVvA Decemha lOtli. ISH'X)
* [Ahstracl.)
A Tabulab Statement ia given of tin; naoro severe cubcb of
ilhioee uuiter tbrc^e headB, wliich inclucle all the cases (I) which
were defaitif'l beifond three toecks, (2) which were tramferrcd to
ot}icr hofpilalit, (vml (3) whidi ended /alallij. A ehort accuuut of
each of the deatha is giveD id a Becokd Of Fxtal Cases.
By t-hiK lu^mis the indiieuc? of the dimiuution of febrile illness
on the d€ath-rat« iti shown.
The natuTV of the iltutisB falliu^ under ench bead is tLoulytied
ID buru, A lie/ of reference to the cAse DUubers ia emh sfiries
is ndi^gd to Chart III, in orduv tt> brlug the cases of eev-ore Uhivsa
au<l the fever-rato into mutual relation Cor each moath.
The general fever-rat* and aejitic rate as given in Chart HI,
and the severe eases of illuees as given in the Tabular Stttti--
ment, talieu toother, iadii.-ate with some degree of preci^ioa the
Btato of the hospital at different pi^riods.
May, 1884,inarkK an important epoeh in the hospital's history.
The condition of the hospiUil WforL' and after that date la
comuieutcd upon and is snnirimrieed in Tabi-k II, wiieriftl atten-
tion being drawn to the ubru^jt detlino <tS eoptic illucss which
occurred at that time.
This Table shows — ■
T/iat the deatk-ralt: from all catuex foUoKf-d !hr. ihcHne in the
general fever-ratp ,- atid thai, as in the oaa aaac Ihti irnprorrm/tnt
reimlied in the main frovi drcrcasr in tha tt'imfjer and eeieriti/ of
caert affected with teptieetmia and pelvic inflammation, to in tha
olhrr the decline tM» main!!/ wrought by decrritte in and trntipo*
rary ahoUlion of the septic eiemenl.
Cunsidemblu pruxreas, as »liow» \>y the ilecreasing di-a.t1i-
late (tht: only criterion available for that distant dato), had
rSTKB IN CHILDBED.
237
been made in tlie eame direction ^irior to tbe commeDc^incDt o£
tho sepN^QQiEil period now under conaiddrntion, but, as far att is
known, no stich compnratiye imtuunitjr from septic illneBS bad
been hitherto attained.
Thd continued decrease in tie death-rate and tbe ateadj
diminntion of febrile iUuess, and especially of septic illneea,
indicate thnt improvifmcnt Is still ^oiag on.
In the foUuvriu^ sectiotie tli*? service of tb'e hospital and tho
changes which have been effected in it will be considered. The
coincidence of these clangs with varifttiona ia tbe condiUon of
tlie hospital will be triioed.
In this section I shall show to what extent tho decrease
in the atnonnt of fobnlo illocsg offootod tbo deatb-ratc.
I would in the first place point out two ways in which
Chart III, when taken by itself, fails a» a perfectly correct
index of tbe total amount of morbility. I refer to those
patioDte who died in the hoBpital, and to those who were
trtkuaferred to other hospitaJH on account of prolonged
illneee.
A Tabular Statement (p. 244) ia given —
(1) Op all reE casks im wtiicn it was pound meckssary
TO DBTAIK THE PATIHNT FOR A LOIfGKK PEJtIOB TUAN THREB
WIEK8 AFTKK DKLITIKY.
(2) 0? ALL THE CASKS IN WHICH THB PATIKKT WAS TKAK8*
TKBRBD TO AMOTHBK HOSPITAL.
(3) Of all TBS CABIH WHICH BHBKD FATALLY.
Tho position which they sererally occupy upon the chart
is indicated by the corresponding and distinctive nurabor
of each series [see Chart 111, p. 235o).
These categories include the more serere forms of ilU
nesB, but without some Riich notification the soeond and
third would not be popresented to the full extent in the
chart, for tho fever in the one case is often cut short by
death, and in the other breaks off when the transfer of
the patient is efTected. As, however, after May, 1884,
both tbe death-rate dccrcanoJ and tbe number of cases
which it wtts found necessary to transfer diminished, the
TOb. xxxu. 17
288
FETEIi IN CniLUUED.
improvement represented by tlie cliart is in no way diB-
counted, but rtither the reverse.
Tliis becomcB Btill more ondent wliea the catare of the
illcesa is taken into coaaideration.
Glance for a moniient at the nature of %ho fifteen fatal
oases. A fihort aocount of each will be found in the
appended Beeord of Fatal Cams (p. 252). They form :l
soitalilo pegj upon wliich to La.ag tliB remarks wbicli I am
about to make with regard to the character of the ill-
DBBaea which prevailed prior to and snbsequent to May,
1884.
Preyious to that date, sis deaths took place among 612
patients admitted, giving a mortality of very nearly 1 per
cent., yiz. 1 in 102, All of thoae cases arc essentinlly septic
in character : — (!) Pyometritia, pelvic peritonitie, and
septic phlebitJB ; (2) severe traumatic inflammation ending
in abscess and purulent peritonitis ; (3) general septic in-
fection ; (4) septic phlebitis and acute endocarditis ; (5)
traumatic hiematoma ending in abscess, pyolymphangitis,
perimetritis, and paranietnfcia ; and (C) pyometritis, septic
phlebitis, and acute endocarditis.
After May, 1884, nine deaths took place among 2150
pEitients admitted, giving a mortality of little more thaD
0'4 per cent., or I in 239, Two patients died from ad-
vanced pulmonary phthiaia, two others from eclampsia,
one from htemorrhage, and one from mercurialism and
morphiniBm combined, in all of which &eptic£Bmia played
no part ; one succumbed to septic phlebitis and genei-al
pyaeuiia ; one to sloughing ot the soft parts and parametritic
abscess following severe iustrumeutal labour, and one to
hospital gangrene. With the siugle exception of one of
the advanced phthisis cases (concerning the nature of which
there could be no doubt), all of these last-mentioned cases
were verified by post-mortem examination.
That deaths from an affection so prevalent an pulmo-
no-ry phthisis or bo fatal aa eclampsia, in BssocJatiou with
childbirth, will from time to time occur among puerperal
patients is only to be expected, and cannot be guarded
PETER IN CHILDBED.
230
against vhea no selection of patients ia ma^e, T)ut may
rather be anticipated in au institution to which the laore
serioua cases natarally gravitate. The point, therefore, to
which I would direct ftpecial attention ia not the evidence
of such casea, bat the fact that while eix deaths occurred
from septic illness among 600 patients before May, 1884,
three deaths only can be attributed to septic influence iu
more than 2000 confinements which followed that date—
a mortalitf bat one> seventh part of the previons death-
rate.
Moreover, the instances of severe and prolonged illneea
which necessitated transfer to other hospitalB tell a pre-
oiaely similar tale. These include !5 cases of scarla-
tiQa which were sent to the hospital oE the Metropolitan
Asylums Board at Stockwell, not on acconnt of the severity
of the ilinesB, but in order to prevent the spread of in-
fection to other patientB. Omitting these, prior to May,
1864, 18 were transferred on account of severe or pro-
longed illness, against 10 subsequently, gi^'ing & ratio of
1 ia 34 against 1 in 215. And here, again, it is found
that septic poisoning played a very subsidiary part after
May, 1884.
For before that date, among tlie cases transferred may
"bo reckoned twelve of pelvic inflammation (of which two
ended in abscess, one of them being complicated by -mania,
one was associated with erysipelas, and anotlior with
typhoid fever and pleurisy ; one with acute nephritis, and
one or two with uystitis) and two eases uf general septic
poisoning ; one of remote abscesses of doubtful urigin,
one of doable phlegmasia doleos, and two of acute
mania.
Uut after that date, two cnses only of pelvie inflamma-
tion appear (both undergoing resolution), the remainder
comprising one of acute mania, one of eclampsia followed
by mania, and one of eclampsia asaocititod with acute
nephritis and followed by otorrhosa and meningitis, one of
ohronio nephritis and ascites, one uf chronic nephritis and
thrombosis of the internal saphenous vein, one of cancer of
240
KKVlilt IN CQILDUBD.
fclie nteruB, one of cancer of the rectum with reot4>TagiDBl
fiBtiila, and cue of veaico- vaginal fistula.
Turning' now to the cases which it was found necese&ry
to detain beyond three weeks from the date of delivery,
the same facts are proclaimed. They uerve to empbasiae
the proof.
Prior to May, 1884, fifty-fivo such cases are recorded.
They include thirty-eix iuatancea of pelvic inQaiuinatioii—
perimetritis and parametritis (the ma.jority accompanied
hy exudation, of which five ended in abscess ; two others
being associated with mammary ab^oess ; two of the
former and oae of the loUer suppurating casOft being
complicated by Toania ; one was aagooiated with gastritis j
ono or two with cystitis; one with iicute nephritis; one with
pleuriHy ; one with ecurlatinn., acute nephritia, and pleurisy ;
and one with typliuid levar and plouui&y), together with
BIX cases of general septic poisoning, of which three ended
fatally ; three additional cases of mammary abscess; two
additional of cystitis; and one each of double phlegmasia
dolens, of remote abscesses, of acute gastritis, of glyco-
8uria, and of general weakness. Two cases which were
probably scarlatinal (one being associated with pneumonia,
mania, and doubEe mammary abscess ; the other with late
perimetritis], and one other of an obscure nature, complete
the list-
After May, 1884, the record laoludea but twenty-six
Buch cases. Witness the difference also in their nature
— four oases of pelvic inflammation (one being associated
with single and one with double phlegmasia, but all under-
going resolution), one case of sloughing of the soft parts
associated with paramolritic abscess whicb ended fatally ;
three cases of mammary abscesB; two of cystitis; four of
thrombosed veins in the lej^ ; one each of chronic bronchitis,
of BCiite plenrisy, of intestinal irritaliun, of nephritis, and
of eclampsia associated with acute nephritis, and followed
by otorrha>a and meningitiH ; two of recto-vaginni fistula
{one being associated with cancer of the rectum) ; and one
of vesico- vaginal fistula. One other patient was detained
FETSR IH 01
S4I
on account of weakneBs resulting from ante-partiim htomor-
rhage, aud ooe on the iafant's account. In tie two re-
mnining c&sos the nature of tbo Illness was aDdetermined.
It will be observed tha-t occasionally the saiUQ case
appears in more than one category.
The facts givBn in this statement are very striking when
allowance is made for the diflerence in the number of
admissions daring each of these periods.
The condition of the boepital before and after May,
1884, ia auramarised in Table II (p. 2(33).
This tuble shows —
That the death-rate from alt causes followed the decline
in the general fever-rate, aud that, as in the one case the
improvement resnlted in the main from docroaso in the
number aud sBverity of oases aflocted with septicaemia and
pelvic inSammation, so ia the other the decline was mainly
wrought by decrease in and temporary abolition of the
septic element.
Conaidcrable progreaa, an shown by the decreasing death-
rate (the only criterion available for that distant date),
had, howerer, been made in the same direction prior to
the commenoement of the septennial period now under
oonaideratioD, but, ns far as is known, no auch compara-
tive immunity from septic illness had been hitherto at-
tained.
Conseqnently the improvement which has now taken
place stands out in greater prouiiuenco Mtill wht-u the
aeptennial period now completed is compared with the
past.
Wo need but took back a few j&ara.
I take the liberty of quoting from Dr. Collingworth'a
able address on "Puerperal Fever a Preventable Diaeaae."*
" Until the year 1S77 this boRpitnl wns scarcely ever
free from puerperal fev^r, and the mortality, always high,
occasionally became fearful. In 1838, of 71 women deli-
vered Ifl died ; in 18(Jl, 14 died out of 195 ; and in 1877,
9 opt of 63. On several occasious the hospital had to be
* L«i»lcn : |inl1isli«d bf J. ud A. ChurcbUt. 1668.
S48 rarSB W OfflliDBBD.
closed for long periods, and thousands of pounds were
spent on tliQ sanitary improTement of the building. In
October, 1879, this institution, taving been closed for two
years, waa reopened, and has since been conducted on
antiEeptic principlea, the details varjing from time to time
113 increased knowledge and experience have dictated.
Mark the result. The total mortality, which from 1633 to
1860 averaged 30-8 per 1000, and ft-om 1861 to 1877 17
per 1000. has fallen during the last eight years to an
average of 6 per 1000."
?<alai. '
DeUvuiM.
DuUu.
ATcragc deatb-Rte from ill tonlrm.
18S3 to iseo
1861 to 1S7J 1
1880 to 18&7
£833
87M
1»0
16
1 in 324 = 3-085 % .
1 in 68S = 1-696 % .
liiil6U-0-Sl8%.
This table shows the progressive decrease in the death-
rate.
During the last two years this average has been still
further reduced.
That improvement is still going on is evidenced not only
by the diminishing death-rate (see Table 11) hut also by
the steady diminntion of febrile illness, and especially of
septic illness, to which I have already called attention.
It is a source of gratification to find that though the
General Lying-in Heapital has not yet attained nbsoloto
perfection, suchcloseapproximation to immunity from illness
is scarcely surpassed by any of its richly endowed Con-
tinental or American contemporaries.
Now, on account of the progressive character of the
decline in the death-rate, which, it may be observed, was
initiated before the era of antiseptics, it may he objected
that the improvement in this respect, and also as regards
the decrease of febrile illness which has since taken place,
has reaolted not from choDgcii which have been purposely
FEVKE IN CHILDBED. 243
introdaced into the service of the hospital, snch as I am
abont to relate in the following sections, but have been
wrought by the agency of natural causes. I shall, how-
ever, when discussing the effect of atnaospheric changes
on fever in childbed in the concluding section of Fart II
of this paper, produce evidence indicating to what extent
natural causes have afEected the condition of the hospital
as compared with the general run of practice. I shall
Bhow how these influences, at one time operative within
the hospital, have for some years ceased to be so. This
objection will then be disposed of completely.
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252
rSVIK IN CBILDBBD.
BecDrd of Fatal Gases.
Tbo nnmbcTs i, ii, ill, ftc.j rcter to the du; of the paerpcrium («■» note,
p. 244).
X. Hosp. Rep. 2»7. Admitted I9th NoTomber, 1882.
Died 3r(J December, 1 882. Partial placenta prrovia, "t-para.
Early rupture of membrauea and artilieial dilatatiou o(
cervix under chloroform. Hsemurrhage, which had not
been seyere, then ceased. Temp, rose to 103*4° before
labour was ccimpleteil, but aftervrarde fell to normal.
Temp, began to ria© again on i, and reached 103° on Ui,
increasing steadily to 106-2'' on xiii, with occasional remis-
sions of two or three degrees, followed by rigors on viiij
ir, and xii. — No regular after-pains. Acute pains in left
iliac region on evening of i, ahdomen distended from ii,
diarrhtBHi set in on iv and retching vii. Localised inflam-
matory cutaneous areas appeared in various parts of upper
limba and on battocke and forehead after is.. Slight
delirivun supervened xii, and death took place xiii. Lochia
offensive from iii, continiiod red but scantyj and occasion-
ally stopped for twonty-foup hoars after vi till death.
Fundua dcL-ltued loss readily than ueual, being stilt four
inohea above pnbes on vii. Deposit recoguiaed in pelvis
by vaginal examination on ix. Milk came iu on iii, never
plentiful, but aalhuiuat till ix, when it failed. — Intra-uterine
carbolic doDohes. Poultices with laudanum to abdomen.
Quinine internally.
PoBt-mortevx. — Old and recent pleurisy. Pelvic peri-
tonitis. Except for adhesionS] ovai'ios and tubes normal.
Thrombosis of right ovarian vein extending to broad liga-
ment and forming a solid swelling, Bizu of a walmit. Pus
in uterine sinuaes.
8. Hosp. Kep. 324. Admitted 30th December, 1882.
Died 8th January, 1883. Cyet (? dermoid) size of fcetal
head, adhereut in pelvis, twice aspirated through vagina.
Temp, rose to 101° afterwards. Craniotomy. Lacerations of
perinaeum and vagina. l-piLra,
PETER IN CHILDBBD.
253
Temp, hftgan to rise i, aiifl rfeacliod 104* on ii, dropped 1*
on iv, but persisted till patient bocarae unconscious vii. —
Collapso followed labour. Severe bearing--down pain i.
Marked njdemn of labia and vagina, and uterua very tcndpr
ii. Offensive lochia from iii, free and red till after V. Viigina
and perineeam sloaghing iv. Abdominal distonsion and
teadopnpss, piiin severe und incren.Binf|r, and togs drnwn up.
Patient Rfl.nk into an iinconsciocB Btate vii, mid died ix. —
UterineandvnginnldoncTies of carbolic nnd Condy. Cathe-
terisin under chlornform, bUdder imgated with carbolic and
Cond/. Morphine bypodermically. Poultices with laudRnnm
to abdomen.
Post-mortem. — Thin pandent Huid in abdomen. Slight
general peritonitis. No cHCiipo of cyst contents into peri-
toneal cavity. Sloogliiiig grocniali cavity round upper
part of vagina, involvingall eoats of blsiddyp,anJ inuPBthru-
viigiual septum. Slouglis on wall u£ cervix, but nut of
body. Old tidliesions uf plearre. Venn cava and iliac
veins hcallhy. Left uvary pale, right injected, both codcnin-
tons and fioftcmed. TubcH not mentioned.
3. Hasp. Rep. 12(i. Admitted 5th May, lfl83. Died
26lb May, 1883. Normal and ~ easy labour, l-para. No
laceration noted.
Temp, began to riso ii, and reached 104° on iii, varying
from 103" to 105'*' with considorablo romiaaionfi and occa-
aiooal intermissions till death. — No after-pains, (ieneral
tenderness over uterus and lochia offensive iii. Maniacal
deliritiTn vii. Lochia, which had changed from free red to
scanty pink iv, and from latter to yellow vii, became free
white and again otfenaive viii, and ceased ix. Uinrrhcen
net in xiii, acute pharyngitis xriii, vomiting .\x, nnd pnca-
monia xxi. Died xxii. Kuadiis hud declined below brim
of pelvis by xii. — BiKmuth, ([uiuinu.
No poat-mortem could be obtained.
4. Hosp. Itep. 132. Admitted lOth May, 1883. Died
2nd June, 1883. Tedious lirHt i^tagu, but otherwise normal
labour. Lacerated perinwum. l*para.
roc. xxxu. IB
2d4
FSVEB IK CEtLOBKD.
Temp, rose euddpnly iv to 104°, Tiu-ied from 104* to 106^
with lunrked reniissions till xii, and 1* lower >vitli slighter
reraissiona till xxi, declining gradually during last three
days of life. — No after-pains. Offensive lochift from iv.
Shivering fit iv and rtgor vi. Cardiac systolic mumiur at
apex from vi. Signs of pneumonia from :s. Diarrh(c&
from XV. Strabismus. Heart murmur increased much in
intenaity xxi, pain in knees and elbow on moveuient, urine
passed involuntarily. Slight delirium snpei'veiied, aud
death took place xsiv. Fundus declined below pelvic
brim vii. Lochia changed from free red to scanty piuk iv,
and ceaaed viii, hut purulent discharge x — xiv. Vaginal
csaniiuation, is, revealed nothing abnormal in pelvis. Peri-
nooal wound healthy. No abdominal distension or tender-
DC83. Appetite good throughout, asking, ivii, for beer and
ranttoD chop, and to be allowed to sit up, — lutm-utorino
douches of carbolic vi, vii, and viii. HiEnuith and mor-
phine. Ice cap and Sod. Salicylat.
PoH-moTiem. — No general or local peritonitis. Eccliy.
moses oa visceral pericardium Jind on vistenil pleurn.
Vegc-tationa on mitral and tricuspid valves, to which adhere
decolourised clots, but it ii^ uncertain whether nlcenitcd or
not. Hypostatic pneumonia. No pu^ aaywhcre. Uterus
hofilthy. Ovaries healthy. Tubes not mentioned. Left
pampiniform pluxua blocked, clot commencing ono inch
from uterus. The clot is old, partly decolourised, firm, adhe-
rent, and sweet. Large yellowish infarct in right kidney
(estimated a fortnight old).
6. Hosp. Kep. 330. Admitted 23rd December, 1883.
Died 8th January, 1884. Tedious first atngCj but otherwise
normal and enwy Jnbonr. Syphilitic fiubjeet. No laceration
found, l-para.
Temp, rose suddenly iii to 103-4% varied between that
point and 104(i'^ till is, whftn it fell, and became sub-
normal xi — xiv, with occasional rises to 102°. — Very little
after-pain ii. Shivered iii, and again iv. Signs of bron-
chitie appeared ili, abdominal distension and tenderness iv,
FXVEB IN CHILUBED.
266
lEToluntary micturition with offensive lochia and urine vii
and viii. Slight deliriniu ix. Persistent diarrhcea eet in
and vomiting xii. Patient became unconscioas xvi, and
died xvii. Fundus quickly declined. Hreaence of exuda-
tion in pelvis ascertained by vuginal examjuation xi. Lochia
fren red (or first five days, scanty yellow and occasionally
blood-atained till cessation xii. — Fomentatioasto abdomen.
,Icacap. Sod. Salicylat. Cathoturism. Bismutti, inarpliine,
and hydrijcj'unic acid.
Poai'Viartem. — Old pleuritic ftdbusionis. Hypostatic con-
gestion and bronchitis. Fibroid induration of heart and
heart valves, spleen, and kidnoys, whicb, in addition, nto
lar^fe and palo. Poritoneuiu, except in pelvis, healthy.
Recent adhesions of uterus in Douglas's pouch. Ovariex
pale and large, but otherwise healthy. Uterus well in-
voluted, and presents nothing abnormal on internal aspect.
Tnbcs healthy. At upper part of anterior vagiual wnll
are two holes with clean-cut edges, each the ai?,e of a. aix-
ponce, one on cither side of tbe middle line, with a ttimilar
bat smaller hole, not larger ihaii a lentil, below and
between them. They i « tore oinmnni cat e, and lead to a
cavity rather larger than a crown piece. The wall of this
cavity 18 iaSltrated with reddislL-yeliow material, and in
two spots, which are adjacent to softened and infiltrated
parts of the mucous membrane of the bladder, in in a
xlanghiag condition. An extension of this cavity runs
towards the base of the broad ligaments on either side, and
on the right reaches very close to the inflummatory focns
there situated. Tlie left broad ligament prettents no such
infiltration, but that on the right cstondB upwards into the
iliac fossa of the name side, where it follows the course of
the ureter to the kidney, and extends forwards along the
round ligament as far ae the internal abdominiil ring.
itcftdsof puti having a chain-like arrangement are collected
in either broad ligament in the space bounded by the
Fallopian lube above, and the ovary aad its ligament
below. On the posterior wall of the uterus beneath it^
peritoneal coat are xeveral tiiiinll purulent collections, gener-
266
PXTEIt IN OniLDDBn.
ally not larger thnn a pea, but one is as large as an altnond.
Many of tieae collections are almost solid iu consistence.
6. Hosp. Rep. 38. Admitted 23r(i Pebi-uavy, 18»+. Diedj
27t-h March, IriS-t. Tedious labour witli gLMierally cont«MJt«€
pelvta, 1-para. Inertia and post-partnni liieinorrliage to the
extent of HO 07.. Pourctette lacerated, but no deep tear.
Temp, began to viae ii, and reached 103'2° on iii. From
ttis point it gradually declined with slight remiBsions to
101*' on viii, but on is again roso to 103'4* eontinuing
betwoou 102'^ and 105° nntil death occurred. — No after-
pains. No abdoiuiual dt.stensioD or teuderuess, the patient
sleeping and eating well to within a few days of death.
Slight frontal headache on x, replaced by occosior
delirium, elight from xii to ixxiii, after which it bocainc
a prominent feature. Slight pain and ewelliug in right
shoulder from xii and in right hip on xxix. Slight
bronchitis from xii. Loc^hia not offeuBive, free and rod for
first four days, yellow after, ceaaed xvi. Laceration hoaled.
Fundus declined naturally and reached brim vi. Cervix
by vaginal examination on xsviii found to be fixed, but no
deposit of appreciable thickaese could be felt. Milk canie
in slowly on iv and v, plentiful on ri, hut disappeared
gradually after xv. Strength began to fail from that date,
and deathtcokplneoon xxxiv. — Sod. Salioj'Int., qmnine, and
digitalis. Stimulants.
Post-mitrtein. — Mitral valveK slightly and one of tricuspid
valve flaps much thickened. Edematous lungt;. Tiivcr,,
spleen, and kidneys present nothing beyond ordinary signal
of fever. Pelvic organs, with the exception of prolapse of
left ovary into Douglas's pouch, bok healthy from abdomen,
bnt on cutting into uterus pus e-xudes from sinuses over
situatiou of placental site (left posterior part). Adjacent
uterine voina contain adherent clots, and also both iliac
veins. Similar clots are foQnd in vona cava as high as first
lumbar vertebra, and in femoral veins as low am middle of
thigh. Uterus appears \'eiy well involuted. No mention
of tubes. Cervix and vagina normal.
VKVER Ih' unimDBj).
257
7. Hosp. Rep. 03. Admitted ind March, 1885. Died
11th March, 1885. AdvauceJ phthisis, very ill on admis-
aiou. Sovere cough fi>r sis months previously and hmmo-
ptysis. Normul labour, -t-para.
Temp, iinmutliat.ely after labour 1(K)4-'^, hut snme oven-
iuy rose to 103*4", and jmrsistpd with variable remis-
sions at 103* — 104° till death. — Little milk appeared in
breast iii. Diarrhcoa set iu iv. Distressiug cough and
dyspucea persiated, patient bocainy gradually weaker and
died ix. No abdominal paia or tundemBSs. Lochia uot
oEfensive, scant;y pink tliruughout except vi aud vii, when
thuy WLToydlow. Fundus steadily declined, uxteiidiug foui-
inuhes above pnbea vi. — Morphine linctiis. Ipecacnaoha.
Ui»Diuth. Stimulants.
No pubt-mortem could bo obtained.
8. HoBp. Rep. 106. Admitted 1 4th Api-il, 1885. Died
22nd April, 1885. Advaiictjd phtliiai»f, vuM-y ill, with temp.
lOl"^^ un adinissioii. Normal labour, 8-para.
Temp, fell below 100° after labour, hub rose same
evening, peraisting at 102°— 104° with slight remissions
till death. — Little milk appeared in broasta ii. Weakness
increased, dyspucea at timea becaiuo excessive, and death
occarred vi. Lochia free red for firsttwo days, scanty pink
aftci" ; not offon.iive. No abdutninal pain or tendeniesH.
yundu.i extended but three inches above pubes ii. — Ips-
cacuanha. Stimiilauts.
Post-viortem. — Hoth lungs riddled with cavities, adherent.
Tubercular and purulent glands in inediostina. Liver
adherent. Kidneys large and pale. Pelvic orgunn healthy,
2 oz. clot adherent to placeatal sito and 2 — 3 os. Iluid
blood iu uterine cavity.
9. Hoap.Rep. 244. Admitted •22nd Angunt, 1885. Died
7th Kopt^iuibor, 18t;5. Mercurialisui and uiorphUin. Already
luportcd. Soo Dr. Dahin's paper on " Mercurialigm " in
'Obat. Trans.,' vol. xxvjii, 1886, p. 200.
10. Hosp. Rep. 20S. Admitted 1 st Octobur, 1885. Died
258
PBVEB IH oaiLBSRP.
19th October, 1885. Post-pni-tum brotnorrh age to tho extent
of 50 oz. ; othcrwigQ normal labour. Ko lacemtion noted.
I -para.
Temp, began to rise it, and reaclied 101°. Sligbt
sliiveriug fit oii vi, and mgain on viii, when 102'8® was
reached. Next day with severe rigor teroperatiire rose to
105'8*, and from this point was very irregular, marked re-
miHsioQB and intermiitgiona, followed by repeated eliivermg
fits aud rigors, oceurred during the next three days, bat on
the whole the fever declined, and temp. appu.reDtly
normal during the last few days of life. — No after-pains
and no distension of the abdomen nor pelvic pain till xi,
then alight and soon passed oS, bnt returned xiii. Bpi-
gsftric pain is, also alight aiid evanescent, but returned
with hiccough ivii. Feeble, irregular, and intcruiittent
palse^ and occasional cardiac bruit from x, more distinct
subsetiuently. Persistent vomiting and purging from xii.
Contiuned hitherto to tnke nourishment well, but stivngtli
now began to fail rapidly. Passed dejecta uncoascioaaly
from XV, gradually sank and died sviii. Lochia variable in
amount; red or pink till x ; stopped xi ; yelloWj scanty xii;
oeaeed permanently xiii j ofiensive vii and viii. Fnndus de-
clined slowly, remained highertban usual, being four and a
half inches above pubes, viii. Nothing abnormal found by
vaginal exnminatioa xii. Milk came in iv, bnt not freely.
Nipples soru vi, afterwards milk luoro plentiful, but almost
disappeared ix. — Wet pack, bismuth, stimulaiits.
Post-mortem. — No peritonitis. Riglit ovarian vein divides
and enters vena cava inferior by two openings au inch
apart, both of which are plugged with soft, highly organ-
ised, adherent clot, breaking down iu ike centre. The
ovarian vein is blocked by chocolate -col on rod, eetai-Boid
clot, which extends downwards to the ovarian plexus of the
samo side, but ends abruptly opposite the inner border of
the ovary, and on carefully slitting up the uturine ninuHeR
nothing abnormal discovered. Abscess in right suprarenal
body the size of a walnut ; the plexus of Teln» lying between
this and ovarian veiu is composed of bhick-walled veaaels.
FBTSB m CHILDBBD.
259
which aremattedtogctli&r and tilled with somi-fliiid grumccufl
inatmnR.1. All other veins healthy. No plugging ou oppo-
site side. Ovaries and tubes normal. Haimurrhagic' spols,
infarcts, and minute abscesses iu kidneys, aplocn, and liiugu.
PftL'chia; under serous covering of lungs, heart, liver, and
iutuatine, beneatli endocardinui, and beucatli mucous mem*
brtiuQ of stomach and inteBtine.
11. Hoap. Rep. 848. Admitted 2tJth Novotnber, 1888.
Died 1st December, l88ti, Eolauipsiu supervened during
iirst stage of labour (two file of epileptiform chiiraeter).
Forceps delivery under chloroform. Stillbirth. Manual
removal of placenta. Perimcal laceration. 1-para.
Temp. lOO-i** i, roee to 104° ii, but declined to normal lii.
Began to i-ise again during last tweuby-foar hours, and
reached 105* juet before death. — Fite continued after de-
livery, two i, and no less than twelve ii. Patient then sank
into Bemi-comatusecoDditiuu, from which she never rallied.
•Tanndice and vomiting set in, and herpes labiaJis appeared v.
Death vi. Lochia changed from fi-ee red to .scanty brown
V, not offensive. Fundns declined to three and a half inches
above pubcs \n, and there remained ; laceration healed. No
milk appeared. Urine drawn during labour deposited one-
fourth albumen with lieat and nitric acid, aud was found to
contain many fatty and grnnular, and few hlnod and hyolino
casts. Albumen decreased to a trace iii, but afterwards
increased. — Croton oil by mouth, bromide and chloral ono-
mata. Chloroform inhalations. Dry cupping. Ice cap.
Past-^wrtem, — Pelvic organs healthy, Ualf ounce dark
fluid blood in uterine cAvltj. Pelvic veins normal. General
deep ictcriu tint. Gall-ducts healthy. Liver substuncu
pale, soft, and friable, granular on section ; capsuli; rather
adherent. Kidney eubstaEOc very toagh, and capsule ad-
lierentj palo on. section. Brain more vascular than normal,
with many fine extravasations on and between convobitions.
Subpleural petechiw. Heart, spleen, and lungs normal.
12. Hosp. Kep. 828. Admitted mii October, 1887.
SflO
KKVICK IN CBI1.DUIC1).
Diet! 31hI Octuber, 1887. Normal l»1>oui-. Slight labit
teai'. 1-para.
Tomp. ran up from nomml to 1(>6'2° in first tweuty-four
hcui-B, then deeliuGd to normal, Ijut agaia rose, and reaoliod
104.° at de».th. — Severe headache complained of swou after
delivery. KctHtnpsia supervened tweut/-foar houra after
labour; ten fits of upileptiform character followed ono
another iu quick succcskiqu. Patient sank into tscmi-coum-
tosu statu, uud died thirty -six koure after deliTcry. Lochia
free red i, scanty ii, uot ofEcubive. Urine on eact occasion
dmwn by catlietoi' found to contain one-sixteenth itlbumen
by boat mid mtrio ncid. — Clilorofonn inhalations. IJromido
and chloral pur re-ctum. Pilocarpiuo EypodermicaUjT. Dry
cupping. Vapour-bathB.
Poet-triorkm. — Pelvic organs normal oxceptovaries, which
arc very cedeuiatouu and cuntuiii numiLTouB small cyBts up
to Hizo of a pea. Heart uud lungs healthy. Kiducy
pyramids normal, bnt cortical substance diniinisLed in quan-
tity a.ud light in colour. Liver light in colour, uud some-
what nutmeg iu appearaMCo on seetiou. Brain uot txaniiuod.
13, Uosp. Rep. 334. Admitted 2nd September, 1888.
Died ^3rd SeptL*mbcr, 1888. Contracted pelvis. Unsuc-
ceBsTuI utteniptB to deliver with forceps made, aud vogii
and cervix lacurutud bufori; iidmisKion. Subaequeut appli-
cation of forccpa iindcr chloroform unsuccessful. Ccpbalo-
tripsy. Lacerated perinteum nusutured. 2-paro.
Temp, begun to riHc gradually from iii, and reached
102'4° is, and, with exception of transitoi-y i-ise to 104"2'^
xiv, reuiaiued 102° — 103" till death. — Extreme exhaustion
followed labonr. Vomiting occurred iii, and rectal alimen-
tation resorted to. Periuieuni sloughing iv, vagina vii,
iodoform bougie inserted j urine offensive, boric acid irri*
gation of bladder. Lochia chnngcd from free red to pink
on vi, inid to yellow on x ; offensive from iv onwards. I're*
queut douches of iodine used from vi. General condition
improved during first fortnight. Appears to have had a
fit xiv^ and developed acute maiiiii, nece:>eit&titig return to
rSTBIt IK CBILDBBD.
notel alimentation and use of cutioplingoal tube. Bnddenly
became rational svi. Weakaoss increased. Uolirium xxi.
Diod xxii. — Stiumlauta.
ronl-murte7n. — Sloughs vi puriua'uiii, vagina, aud i-crvix.
Budy of atcras liealtliy. Tubes nut iiit-utiiunod. Ovu-ries
nuiinal. Abscess beneath right iliacus couuectud with
sluugh on vaginal wjvll, situiiiud oni; inch beiaw cervix i>u
right Bido. B;>lh broud ligunieuttt Lontaiii uattcouttdepufiitH,
iLud the cc-Ilular tissue is hard aud dense. No indicfttiuu o£
peritonitis.
14. Hosp. Rep. 581. Admitted 4th October, 1888. Di«d
I2lh October, 1888. Normal la-bofti". Slight puriiiaiul tuur.
I'piiru.
Teinp. began to rise iii, and reached 101°, ran up to
104"4° V, but fell iiumediately. Kosc from normal tu 1U4*4°
again viii, but declined inimediateEy, and ran up tigniu to
103° jntit before death. — Un.ia.sts beciimu distended iii, bnt
patient seemed going on well till v, when perina'n.1 tear
looked unhealthy; headache. Lochia changed from froe red
to scanty pink vii, offensive from yii. Rigor Tiii, alight
abduMtiual pain and tenderness. Patches uf phlogmuuuut)
cellulitis appeared on left shoulder and buttuck is, inid
spread rapidly; butt^ick incised freely under chlorofurm,
ga« and iiiiniou<t fluid e.>}capcd ; oppression iLt chest ; collapse
and death same day. — Quinine. Peultioes. Sublimatoijubiiti-
tuted for aalufer day before deiitb, and iutra-nteriiiL" douche
given ix, washing out. offensive membrane aud clot from
cervix.
Postfiiortem. — Ilapid putrefactive changes in organs and
tissues. Gangronuus cellulitis uf shoulder and duisuni,
buck of left thigh and culf, in region of left ankle-joint.,
Qud on sole of right foot (surmounted by large bulla con-
taining saniourt fluid). Bhick ami sloughy discoloration
can be traced almoi^t coutinuonsly from slight tear of pori-
u&;um to gangrenous focus in left buttock. Dlood-stsiiued
iluid in pleural, pericardial, and pentoneal cavities. Heart
cavities contain tarry blood. Marked post*mortcm slain-
262 rSTBB IN CHTLDBSD.
ing of endocardinm. Femoral veins and veins of broad
ligaments filled with dark, semi-fluid blood-clot. Some of
sinnses beneath placental site filled with yellowish-brown
gromone material, nterus otherwise healthy. Ovariee and
tubes healthy. No purulent collections. Submucous heemoiv
rhages in bladder.
16. Hoap,Bep. 236. Admitted 27th June, 1889. Died
same date. Admitted on accoant of severe accidental
haemorrhage at seven and a half months. Rupture of mem-
branes, artificial dilatation of cervix and podalic version
under chloroform. Stillbirth. 5-para.
Post-partum haemorrhage to extent of nearly one pint.
Hand introduced. Collapse and death one and a half hoars
after delivery.
Post-mortem. — No abnormality beyond signs of htemor-
rhage.
PBTBB IH CBILDBZD.
III. The service oj tht Hotpital during thin ge^tejtnial
jterxod ; ijicreased' attention to points o/ yenerai
hytfiene ; constant wk of antiseptiat.
(UMMTcd I>««»il>«T lUth, L8S0.}
(Abatrad.)
A (lescriptiLiu of tbu Hi>spitul iiiid of tbc melhod in which its
wrricc hits been oanductctl is dotailed. Such altemtions oC a
gtovinl hygii-^oic uattire as \ta.vQ bt-en cfEtuteU during tbc period
under considomtiou are dwutt upon.
Attention is direct«<l to the fact that duriui; the wbolc of the
time the sauie ijriucii>1e8 bare preniled — a^utisqiticH hare been
in tioost&nt use, but ihc details bare been chan^ng. ui)pcut«Uy
with tvgard to the strength luid character ot the eotutionn «!tu>
ployud. Tbueuwill be euiisidered in detail ia the two suix-eeding
aectiouH.
Abont four years ago, through the instrnmentality of
Dp. Priestley, the Fe-Uowa of tbiu Society were made con-
venmnt with the maoagement of some of the lying-in
liuspitals in the north of Europe. 3 feel, therefore,
encourag-ed to place on record a short description of the
Bcrvice of the hospital which has provided material for the
present paper, Siich description will serve as a fitting
prelude to the changes which have been effected iu tho
aervicc duriug the period now under consideration.
Situ anc .Steucture. — As regards the General Lying-in
Hospital no structural alterations have taken place dnring
tho aoptonnial period above referrod to, nor indeed for
some years before that. Founded in 1765, the hospital
occupies a position on the south side of the Thames, in
the densely populated part fif Laniheth m-iginally and not
inaptly called " The Marsh." The present biiitdiog,
erected sixty years ago, may bo said to cojnpriBO eight
wardii fur tho aocomuiodutiou of lying-in patients, distrU
FKVRR IN CHILDBED.
2ft5
buted on tlie ground aod first floors. Moat of the Ij-ing-in
wards contain three beds apiece ; one rather larger than
tlie rest liaa fonr, tlie cnnvalescent ward four, the isolation
one — giving a total of twentj-four beds. A clear cubic
space of 200l> feet ta allowed for each bed. Encli floor is
provided with a> labniir ward for the reception of one, or,
if occasion require, of two pntJents.
The Willis and ceilings of all the wards arc painted.
An uttcHipt has boon made to polish tlio floors, but, except
in ono of the labour wards (which was laid afresh nith
teak four years ago), was nbandonod in conscqueiioo of the
unsuitable uatare of the surfaco prosouted by the old deal
boards.
Braisaqk.— Cloaets and slop-sinks are provided on each
floor, built out in a turret from the main building, and are
80 consti-uctcd as to include a passage whicdi is shut off
from tlio corridor by doora and ventilated by meauR
of open windows on either side. All the di-aine run out-
side the building, and are furnished with traps for iuspec-
tion and ventilation in the four-foot area which surrouuda
the hotipital on the basement lovol. Th'O drains arc dio-
coiinecl&d with the main by n diptrap, and iire fhisihed
autoraatically every twcdvo hours by nioaus of a lOO-giillnn
trAuk placed in the tower which surmount» either vring of
the building. The fioil-pipes are ventilated by a continu-
ation upwards of the shaft above the top of the building.
VxirriLATioN ANii WABiliNa. — At very conBiderabIc outlay
hot-air pipei* had been laid oa throughout the hoi^pital, and
each ward had been provided with an outlet veutilnting
shaft; but 8f> inefficient did this method of ventilation
prove that for the l«st ten years tlioy linvo been discarded.
A fire, howovor, is kept constantly burning in the open
grate, and all the windows open at least six inches al top
(the amount depending on tlie state of the weather), and
the inside Venetian blinds turned so b» to direct the in-
coming air-current upwards. In one ward, in which all
the windows are on the same aide, Tobin's tubes are also
provided. Inlet veotilatora are also placed near the floor
2«0
FEVER tM CHILDBED.
and Sherriagliam valves at tlio cpper part of the ootor
wall in all the wards.
CLOfHitfOAND Bedding. — Kach lying-inward and delivery
room is provided with its own set of iustrumenta and
nteuBtla. Hnir mattresses are employed. The requisite
supply of bedding and clothing ia given out direct from
the store for each ward. It is strictly forbiddeu to
transfer clothing or bedding, or instrutnentB^ &o,, from
one ward to another. Both infants and mothers are
provided with special clothing throughout their 8tay in
liospital. A cot 18 placed in each lying-in ward for the
accommodation of two children. The clothing in which
tha women enter is removed on admission. This used to
be " staved " and laid by in the hospital until the patient
iVBB discharged, but isiuce the outbreak of scarlet fever,
now nearly sis years ago, it is in many instances removed
by the friends and, together with a change of nnderltnen,
brought back when the patient leaves. The laundry-work
is contracted for outaide the hoBpilal. All soiled linen
used to be soaked either in bay-salt soltition, in order to
remote the blond-stains, or for some time after the scarlet
fever in 1 in 40 carbolic solution, but of late it hati beeu
despatched three times a week to the laundry without being
previously dealt tvitht When returned, the clothes are put
into a Frasev stove, which uEtid to be raised to 220* F.,
but since the above-said scarlet-fever period to 250* F.,
more, however, with a view to airing it efficiently than of,
effectually destroying infection, Until within the last
three years, not only the personal clothes and bedding,
but the niattressps also were before use "stoved," with
the idea of ridding them of possible infection, but, as in
the stove with which the hospital is provided it was found
impossible to maintain the heat for a sufficient time with-
out injury to the fabric, this practice was discontinued.
At the same time each mattress was numbered, and a
legistor was instituted of each patient for whom it was
nsed, so that nny defect might be at once traced. Any
mattress which has been used for a case likely to infect it
FBVEB IN CHILDBEU.
267
is, Tiowever, at ouce sent away iu order to undergo disin-
fection by superheated steam.
FirMiOATlON AND Cleanihq. — The labour wards aro fumi-
gated and washed after every six deliveries. Tlio lyiug-
in vards are disinfected after the beds hare heen onco
occupied. When a ward is vacated by a batch of [latientu,
the bed-linen ia remuved, but the iiiattres»eg and hlaakets
are suffered to remain suspended during the process of
fumigation and removed afterwards. Five pounds of sul-
phur are burnt; in the lying-in and two pounds in the labour
wards. The ceiling, walls, floor, bedateads, Ac, are then
washed down with carbolic solufciou I in 20. During the
last three years the famigation has been performed between
each batch of patients, the additional washing between
crery other batch. Before that it was the practice to fumi-
gate, to wash, and then to fumigate ngaiu, not between
erory batch, but between every other b«teh of patients.
Staff. — BeBides the physicians, who visit twice a week,
the Htaff consists of a Louse physician, who usually remains
in office for about six months and resides continvioagly in
the lloppital ; a matron, who manageH the housekeeping
and Buperintendg the niu'oing, aud a head midwife, who
euperrises the cases in the labour wards. These are the
only permaaeut memherB of the resident staff. But tho
hospital posscescs a flourishing training school, both for
midwives and mirses. Tho former nre received into the
hospital for a period of three, the latter of two monthB.
No pupils from outside are admitted, but there is a large
extern department connected with the hoKpital served by
separate midwives, who reside in their respective districts ;
and, though the pupil midwives attend during part of their
training, on cases in the liome district, they are lodged
meanwhile in the house of the midwife under whose super-
inteudencc their cases are coudacted, mid are not permitted
to take pan during that time in practical work within the
hospital. Whilo on dntj within the hospital, both mid-
wives and uiirseaaro required to droiju in washing material.
Separate day nurdee arc provided fur eB,ob ward, otid a
2Q8
7KTRII IN CHILDBED.
Separate niffht nurse for each floor. The nurses nSRist nt
tlio labour cases in rotatiuu.
Admission op Patients. — Patients are admitted by letter.
The only applicants considered unsuitable are those
affected vritli foul wounde, which wonld entail risk to other
putionts. Single women in tlie first confiDemeiit hre ad-
mitted ott special conditioDS.
Conduct op Laroub. — Patients are more or less advanced
in InbouT on admission, and nre condnctod at once to tho
labour ward. They aro iinmediately dressed in hospital
clothes, and in all cases whero tima will allow the passages
are irrigated with throe quarts of antiseptic solution before
delivery, the doucho being repeated it the labour bu pro-
Icugcd. One or more such vaginal douches at a tcmporn,-
tnre of 115° F. aro invariably given after labour ia com-
plete, and any considerable tears about the vulva are imme-
diately closed by suture.
CosDoCT OF Lying- ly. — Two hours later the patient is
rpmnved on a trolley from tho doliverj'-rooni to the lying-
in ward. Patients are restriotcd to a slop diet Lniil the
bowt'la have been freely rolievod, but generally on the
third day fish and afterw.irds meat is given. A liberal
supply of milk is allowed, but no stimulants unless speci-
ally ordered. Prior to 1884, however, it vraa tho rnle to
Pfive beer with dinner after the fifth day. It was discon-
titnietl on the ground that the patients were frequently ren-
(Icrod uncomfortable and feverish for a few hours after it
had been partaken of, and suhsequout exporioncehaa tended
to confirm this when it has been given in individual casoa.
After the fifth day, the patient's friends are permitted to
vifiit on two aftemoous in the week. As a rule, patients
are allowed up in a tcmlative way on the ninth day, and
all are carefully examined by the visiting physician pre-
vious to departure.
Antiskh'ic Mkasokes, — The vaginal douche at a tempe-
rature of 110° F. 19 employed as a rontine measure nigbt
and morniug until the lochia have ceased. From three
pints to two quarts of the solution are used on o&ch occa-
FEVEK rit CHILDBED.
269
sion. PnJs of absoiTiont cotton and onltom and latterly
of sublimHted wood-wool are osed instead of diapers, aud
when removed are immediately burnt. Cotton isalso em-
ployed instead of sponge, and destroyed in the same way,
Tbo external genital organs are washed with the same
antiseptic solution as tho douche.
In each delivery room and lyin^-in ward three baains
are provided — one for washing with soap and water and
the other two for disinfection with antiseptic solntion, one
for the hands, the other for instrumenta. Immediately
before and after touohing the genital organs of any patient,
it is etrictly enjoined that the hands and wrists should
first be washed and afterwards thoroughly rinsed in anti-
septic solution. Special attention i» directed to the nails.
All iustrumeuta such as catheters and vaginal tubes, wheu
not iu use, arc coustantly kept in autiseptio soluiiou. An
autieeptic lubricant is also used.
It will thus be seen that precautions are taken not only
to prevent tho introduction of infection into tho hospital,
but also to prevent it from being spread from ward to
ward or from patient to patient. These precnutions are
admittedly iinpi^rfect in certain particulars. I need but
instance the admission of vieitors and the employment of
the same nurse in the delivery and lying<in wards in this
connection. It is difficult, however, to see how, short of
liavinfi^ a separate room aod a separate nurse to eacli
patient, more stringent regalations could bo laid down
with a view to prcreut the transmission of infection from
paiicint to patient.
Certain it is that the service of a lying-in hospital
necessitates upecial precautions, for, owing to the close
proiimity of piitients, the risk of conveying infection is
greater in nncli an institution tlian in private practice, where
they are more scattered, lint the risks are precisely tho
same in kind, the difference is merely cue of dogreo.
The same principles underlie the methods of precaution.
It is, therefore, an easy matter to adapt the details of tho
one to the practice of the other. It is thus that the scr-
voi.. xxxii. 19
270
fETKB IK CBILDBXD.
rice of &a hoB^it&l iinds its eobo outside. In botb atri<
adieaion to points of detail, founded on a rational UDder>l
stMidin^ of the princijjEes involved, is called for. With-
out this, error is liable to erepp in and failnre to onsuo.
T]ie cbarts before the Society record, with greater accu-
racy than any mere words of mine can describe, what tn&y
be attained by attention to points of detail. It is not the
mere use of antiseptics, but the method of usiug them and
the faithful carrying out of details oonceraiug theirappli-
catioii, which calls forth their apcoial virtue.
Now, during the whole period to which these charts
refer the eame principles have prevailed — ant jseptice have
been in constant use, but tho details Lave been changing,
and even now cannot bo looked upon m perfected. The
result, as far as it goes, lies before you in the facts which
I have already presented.
In justice to others, however, I wonld point out that
the present condition of the hospital has resulted from an
ever-increaaing espericncc, aTid ia the ftccHoiulative effect
of the labours of those who hare paid ottention to the
Bame sabjoct. The conditiun of the hospital, even at the
present time, cannot be regarded as absolutely perfect.
It now remains to consider the detaila which more par-
ticularly pertain to the various antiseptic agents employed.
It is chiefly with reference to tho strength and character
of the iintisoptic stilutiouB that several important chang'es
have been effected.
The reading of the remainder of this contribution vras
poBtponed till the next meeting.
JULY 2nd, 1890.
AuEiD L. <]rALi.BiH, M.D., President, in the Chair.
Present — 39 Fellows and 6 Visitors.
Booka were presented by Dr. A. H. P. Barbour, Dr.
Lowers, and the London Hospitnl Medical Staff.
Alfredo Antnnes Kanthack, P.R.C.S., nnd Fredericlc
John McCann, M.B., C.M.Edin.j were elected Fellows of
the Sooiotj.
The following gentlemen were proposed for election : —
Richard Ackerloy, M.B.. B.S.Oxoii. (Ashburton) ; Arthur
Norraan Boycott, L.K.C.P.Lond. (Purley) ; William Ilenry
Laurence Copeland, M.B.Cantab.; Charles. David Green,
M.D.Lond.j B.S. (Upper Edmonton) ; David Berry Hurt,
M.D.Kdin. (Edinburgh); Harold Low, M.B.Cantab.
(Sydenham); H. B. Osbiirn,L.R.C.P. [Clapbnm Common);
A. W. Mayo Bobson, P.R.C.S. (Leeds) ; John WiUiara
Taylor, P.R.C.S. (Birmingham) ; WaUer Tyrrell, L.B.C.P.
Lond. ; Samuel W. Whcoton, M.D.Lond. (Clapham
Common) ; and Edvfin Francis WTiite, P.R.C.S. (Putney).
272
DECTDUA VERA AND REFLEXA FROM: A TERT
EARhY ABORTION.
By G. E. Hermait, M.B., F.R.C.P.
The speolnien exliib!tcil wbb passed by a nalliparo. She
began to be nnwell Bve weeks after tlie last menstrual
pei-icid, !in<l on tbe second day of the flow complaiaed of
great paJu, aud passed the fonuation uow exhibited. Dr.
Herrasn -was indebted to Mr. W. T, Lane for the speci-
men. It cousisted of what looked like a cast of the
uterus, and was evidently the deeidiia vera, formed by two
triangidar pieces of thick membrane, smooth, but traversed
by many fine sulci within, rough without, and united at
what corresponded to the junction nf the anterior and
posterior uterine walls by membrane so thin as to be almost
tranehicent. One of these pieces had been slit up tho
middle, BO as to show the inner surface of the menibrnno ;
and on it, close to the fnndtis uteri, was a littlo cup of
membTane about large enough to contain a pea, evidently
the decidua rellexa. The opeiiiag of the cup (decidual
umbilicus) was jagged, as if it bad been torn. The ovam
hail either escaped or wng too sniidl for identification. The
decidua vera naa IJ inches k'ug by IJ- wide, and ^ of an inch
thick at the thickest part. The decidua reflesa seemed
hardly thicker than paper, Thci diameter of th© cup
which it formed was about jj of an inch.
The epecimen tvaii ia the London Hoapital Museum.
Dr. Herman was not awnre of any specimen, or drawing
of n Bpi'cinien, showing the hnm&n decidua rcficxo at ao
early a stage.
273
FCKTUS, PLACi^NTA, MKMBEANES, AND FALLO-
PIAN TUBE; fKOil A CASE OF RUPTURED
TUBAL GESTATION, COMPLICATED BY A
LARGE HiEMATO-SALPINX ON THE OPPO-
SITE SIDE.
By C. J. Cl'I-LINOWOBTH, M.D.
Dr. CcixiNQWORru exhibited a footoB, placenta, niem-
branoB, fttid loft. FallopiBQ tube, from a case «f ruptupad
tubal gpst»tion. Abdominal section was perfonned five
and a bn.1f ilayn after the presumed ilat« of rupture, and
the dingnosis was confirmed by findmg in the pentoneal
cavity, along vnth a large quantity of fluid blood, a foetus
2i iuuhes lu length, stdl attached to the ci^utents of the
uac by tho unruptured fuuU. The placcatu (which was
the seat of au c3:t«nsiro baimorrhage of older date than
the rupture, and was therefore of interest in connection
with a paper recently read by Mr. Bland Sutton before
the Royal Medical and Chirurgical Society] was partially
Ei'paratod and protruding from an aperture in the wall of
the left tube measuring 1^ x 1 inch. The right tube was
diateuded with fluid, and formed n large, teuse, uurup-
tuied, obluug tumour, situated behind thy right bruud
ligament, and adherent orer ila whole KUrfacc. The (luid.
was viscid in character and of a dark hrowu culour,
evidently consifiting of mucus and altered blood. Tlic
effused blood and foetal producta had tho odour of com-
mcncing decomposition, and the patient at the ttuic of
operation was HBptictemte. Her condition fur tko lirst
few daya was uot promising, bat there was now every
proHpect of recovery.*
* This pnticnl CDiitinuud to proitrtiM ntUfa(!Uir%. Sliu Inft tho lioii|itLil,
us wistks afUr the Ajicntion, in gf,r>A liealtli, bat witli a ■innU uuu*, (till
dii*chitrglng, ut (be lower Migic of ilie iuci«ian.
274
ECPTUEED TUBAL GISTATION.
Dr. Hbywood Smith asked I>r. Cxitliugwortb whether he had
removpd the hteiiiato-salptiix, anil whether lie had any theory as
to the formation of the hieniiito-salpjini on the right side, also
whether ite oncoming ha<I njiything to do with determiuiag the
rupture of Ihe oviduct on the left, as it li&d ruptured rather
«arlf.
Mr. DoB^AN was incliiied to beliuvu that, id souke citaes at least,
the " apoplexy " o! an ovum was jiroduced by Ui*? application
of the Hgature at the up«ratioa, and consequent eugorgement of
the vesBels ou the distal side. Ecchymosea and extravasationa
were often observed ou Ike aurfaee of Biuall ovarian tumours
ahao&t immediately after tightening of the ligature, and before
the 8UTg«ou had time to cut through tli<i pedicle. If such an
accident could occur in a cyatlc tumour, where the vessels were
usually normal and healthy, it must be much more jirobabJe
and frequent in the ease of af<Btal cyst of the tube, where the
veBHtjla wwre in many respects ahuormiil and diseased.
Dr. CcLiiNGi WORTH, in reply to Dr. Heywood Siiiitb, said
that the patient hsid migsed two menstrual periode. and that
fact, together with the length of the foetus, seemed to iodicate
that the pregnancy had reached the begbiniug of the third
month. He had not as yet heen abEe to traee the history of the
hffimato-salpinx of old standing on the right side which he had
found and removed along with the adjacent ovary. With regard
to Mr. Doran's reniart as to the possibility of the clot in tha
placenta having formed as a couseq^uence of the application of
a ligature at the operation, be felt sure that any candid and
carefnl observer, looking at the speeinien, would see that such
au (explanation, in this partieular case, vrm entirely out of the
question. The clot was quite old.
275
FEVER JN CHILDBED.
Part I. — Gevbr&l Hygieni amd Antiskpsib (eoniinued).
By RoHjjKT BoxALi, M.B., B.C.Cantab., M.R.C.P.Lond.,
ISUBTAUT OBSTBTBIC PHJBtOUK TO, AND ISCITEEB OS FHAOTIOJU.
UIUWIVICKY IT, TBS UlilbLBSItX HOliPITAU
<It«celved Dccembor 10th, ISSS.)
(Abatract)
IV, The. eompanitive value vf various antlnepUc ogmiin }
antiteplicH of the carbulic and Ci/ndy era; ndvantage
of stihltmale over carholic acid and Oondy't jlnid —
rhemiral inronLpatihilify of the latter; (fradual decline
of eeptic iiilfuence efi'ded hy syetematic attcfition to
pointe of general hygiene, and by tht progreitsivB elaho'
ration of antiseplic detaile.
Tliv partivukr antiiibpUo ugouts wluvh liavc bccii useil at
diftwn'iit parts of the period now under coasideratioii jire given
iu Tablb III, anil arc uW rougbly iudicatt.'d on Cbart m.
Thia »how9 —
(1) That the marked improvement which occurrfd in Maij, IRBl,
coincided in point oftivie Kith the sahntituttmt of sublimafffor car-
holic acid and (hndi/'i jtuid at the general andaepttc* emphyed.
(2) That the gradual decline of teplio injlunicc which preceded
that dale atat tffected leithout chanijc in iKt antiteptie emplcyej.
The antis«ptt08 usnil during the carlwlie and Con<ly era are
coi)«i(ltn?(i in detail,
Tbp Waring oE the clieuiical tiicoiiiimtibilltv of tho agents
Biaploycil during the cnrboUc Uud Coudy era is discussed.
The gnidual dflchne of septic itifliienoe obwrvod during th«
later moaths of that en, i* attributed in part to tbo oudeuvour
whicli waH at that time made to obriato the reduction of the
276
rKVKK IS CaiLUB&D.
pcrm&ngaDatc in tLt.- solution employed iov washing and doucbing
thti ]>uttcut, and in part to the greutei* efficiency of tbo iniilwivea
and niirges, owitig totbuadoiftioaof definite rules und directions
for their giiitiaiice.
It ia rema.rked tbiit bho &j8t«matic application of general
hygienic and autieeptic miea to the aervicc o£ tlie iuetitutiou, not
only lod to a gradoal reduL-tiou in tlie fxe^uency and virulence
of general septic iJlnesa, of jvelvic iuflatun)utiuiui,of imhoattby
lesions of the gcnitiUs, and of mammary iuftammatioiiit and of
cases of C}'atitU aiiioag tlie [juerpem; but at the same time
effected a decrease in the cases of ptiriilcnt ophthalmia, of offen-
sively diwharging navel, uf tlii'neli in infants, and of abscesBes
on the fingers among the nurges.
It 18 concluded —
(1) Tliat the gratluat decline in leplie injlucnce obterireJ in
thf earhf monlhii of 1S.S4 tons hrou^ht about in part by st/gt/rmalitl
af tent ion to pointt of ^rneral hiigitt\e,wore particularbjon ihir pari
of the midiaivrsantl nuricH.and in ■pari htf the progressive ftabora-
tivn of drtaih concermni/ the mm of thu antisdptict employed.
(2) That thr marked itnproitemfint lehich took place in May of
the same yrnr irax eff'eisted in part liy the »iih»titulion qf tublimate
for curhoUc acid and Condi/^ k Jluid at theijeneral antisvptict in utt,
and in part itf the continuance of the name beneficial injlueneea.
CVrtaiu relafses wliivli have taken place siucti that dalu will
be dealt with in Section V,
In this and tlio following section the autisoptic agents
iu uso at diffci'out parts of the period now antler con-
Bider&tlon will be indicated, and their relative value dia-
cnased.
In estiiDHting their relative value, the death-rate, the
general fever-rate, and abovo all the septic rate afford
useful data. To the close relation of these several factors
reference has already been made. Other indications off
the decline of septic influence will he given iu tbissecfcioa.
It wiU be shown —
(1) That the marked improvement which occurred in
May, mS4, coincided in puint of time with the eubatitu-
877
tion of Bublimato for carbolic acid and Coudy'8 Raid as
the general antiBeptics employed.
(2) That tlio gradual decline of septic inflaeace which
preceded that date was effected without chanfrs in tlie
antiseptic employed.
It will be further demonstrated that two elemeuts have
combined to bring about this result. These are —
(1) Syetemhtic attentiou to points of general hygiene,
more particularly on the part of the uiidwJree and uurees.
(2} Progressive elaboration of details couoorning the
use of the antiseptics employed.
It will be pointed out that these elotnonts being estab-
lished before, have continued in operation throughout the
sublimate period, and on that account cannot be di»-
regardtfd in eatimatiug the value of sublimate as compared
with cai-bolic acid aud Coiidy's fluid. Nevertheless the
elimination of septic iuHueuco at that time waH so cumplulu,
and has bei-n no perHi»tentl\* maintaineil, a» to establish
fully the surpassing ralae of sublimate as an antit^eptic.
Hitherto I have, in dealing with the service of tho
hospital, oiftrcly indicated the broad fact that autiseptica
wcro employed for the hands, for instruments and ntonsilg,
for washing and douching the patient, and for lubricating
purpoHGti, but I must now uieutiou the particular ageuta
which have been nsed for these several purposes at
different parts of tins tteptennial period. They are given
in the following table {Table III, p. 284), and are also
roughly indicated on Glinrt III.
Until the begiiininpr of May, 1884, both phenol and
penuanguuiktu of putas&ium were employodj and from that
time onwards porchlorido of mercury, and for the most
part perchloridc of mercury only.
It IB instructive to observe bow closely variations in
the condition of the hospital followed changes made in
the antiseptics employed. 1 have already stated that the
sudden fall in the fever-rate, which followed the siibstitu-
tion of sublimate for carbolic acid and Condy's fluid wafi in
the maiu due to the practical abolition of septic influence.
276
rxriR IN CBILDBEU.
The relative value, then, of these agents as antineptics
finds expression in the pyrexia chart, though not to sacfa
an extent as mi^ht be at firat sight supposed. For
though the aublimato shows an immediate, considerable,
and Bustnined advance on the carbolic and Condy era,
causes other than the mere change of antiseptio were
already working in the same direction, and ever since
have cOQtinuod to exort the same beneficial in:9aence.
These causes I shurll have occasion to specify ppoaently, and
to point out the part which they played in effecting this.
But in any case the improvement, taken as an index of
the efficacy of sublimate as compared with carhob'c acid,
and more particuhirly of sablimate aa compared with
Condy's fluid requires to ha considerably diaoountod, for
reasons which will immediately appear.
To one matter of detail it seems to havo been reserved
for tne to direct Bpecial attention, I allude to the incom-
patibility of the chemical agents employed as antiaeptics.
I must refer to my original commHuieation* for particulars ;
it is antHcLent for the preseut purpose to state that, taking
corrosive sublimate, carbolic acid, iodine, t;alicytic actd, and
Condy's fluid as examples, I show'ed that many iustancea
occurred in which, when brought into contact oue with
anolher, or with certnin lubricants, chemical action took
place -, aud I here reproduce the annexed tabic for purposes
of reference. The crosses in the table, which occur at
certain intersecting points of the horizoutal and vertical
columns, indicate that interaction takea place betwcoo
the agents which stand at the head of those columns.
In condemning these admixtures as chemically incom-
patible, I am prepared to admit that iu some iustanoes
the newly formed compounds may possibly be powerfal
antiseptics, though this remains to be proved; and 1
would submit that any observations made with a view
to determine this point are prEictically valueless, uoleaa
either these newly formed compounds be isolated and
• '■ Tliu Clit'initril liicoin[jiiiibllilj of Antiseplii; Agents." ' Brit. Ued.
Jouni.,' vol. i, 1888, p. 898 ; nnil ' Lnncot,' vol. ii. 1888, li. Oas.
FBTES n< OHILDBID.
87V
used in pure solution, or tlie admixture W made !□ such
proportiou thut nt least u» apprecioblo esceefl of eitbur
one or otlior of the original antiseptic coostitaents be
laffcTod t^3 romnin in the tost solutions pmployad.
X
a
8
8
k
s
C
a
s
1
1
H
M
K
M
1. CorToslte8ablimMteSolutii>n(PM-l
chlnride of Mcrror^] . . )
S. Otliolic Botvt'ion (Plmnol) .
5. lodLn« Solntion (Iodine mid Iodid« 1
of PnUuMintn) . , . , J
4. IJNlicjlii; Sulalion (Salicylic Acid)
6. Oonilj'i Fluid (P«nuHug«iiKte of 1
Potvwiutn) , ( * .J
N
K
X
We proceed now to consider the antiseptics of tHo car-
bolic and Condy era.
Prior to May, l884j carbolic solution (phenol 1 in 30}
was employed for hnnda, for iiietrunionts and uteuHilgj both
at the timt' of delivery and during the lying in ; for douch-
ing and washing the patient both carbolic and Condy were
employed (phenol 1 in 40, permanganate of potRssinm 1
in 80()0 = Condy's fluid 3J to Oj), the latter before labour
and in the lying-in wards, the former for the first douche
after labour only — if even a second were required in the
delivery room Condy was snbstitatod ; for lubrication
carbolieed lard (1 in 20) was used until Jnly, 1883, when
carbotiaed oil (I in 20] was substituted and used for that
purpose both during parturitiuu and puerpery.
Into this arrangement the importance of the chemical
incompatibility of the agents employed intruder itsself.
Ah wo are now denling with points of detail, 1 shall dis-
pose of the least important item, the Inbrioant, first. Now,
carboliaed oil (and a similar criticisui applies to carbotised
280
rETBB nr cuilsbbd.
Inrd) IB little if at d.11 gtipGrioi* from an antieeptio poini
view to olive oil alono. To my mind it is a matter of
little importance whether the luhricant be antiseptic as
well as aseptic, provided whatever it may he used to lubri-
cate he previously reudered aseptic. But carboliaed oil,
through its supposed autiaeptic property, engenders a false
scna& of security whicL is apt to lead to the otuiseioQ of this
very precaution — to the disregard of more efficient out-
works bpcause it8 own position is considered iniprog'Dablo.
But even this is a inp.tier of secoudnry importaBco wbon
it iit couiiidered tliat carbolised oil, liko both tho carbolic
acid aud olive oil from wliicli it is made, destroy penuau-
ganate oFpotassiuiii. Add to this the Fact thnt Ihe passages
were saturated 6rst with Coudy's fluid, ilivn with carbolic
acid, and then with Condy's fluid ag&iti, and that it was the
rule to Goak the hands and instruments in carbolic liolatioD
before touching the genitals, and the additional fact that
a very little carbolic will reduce n relatively large quantity
of Condy solution (1 part of I in 20 phenol solution will
turn brown nt least l:i()(.l pitrtH of 1 in HOOO permnnganntc
solution), il may be judged that this imitnal destruction
of tbf ageiit« employed often led to the total annihilation
of the Coudy's Buid, aud thut the system of antiseptics
was thereby reduced in efficiency.
MoreovLT, through the mere fact that the game douche
apparatuH was used for both solutionis, and that thova.ginal
pipes were constantly kept in carbolic solution when not in
usoj it happened that, when I first became connected with
the hospital, the permanganate in the douche was as often
as not completely reduced before any of it was brought into
contact with the genital passagesj so that septic niattoi-
was afforded a ready opportunity of forcing the position.
It WHS our coDstiint endeavour to prevent this, nod to
insist that no Condy douche should be given which had
already turned brown, and that, when given, it should be
continued until it returned unchanged in colour. To the
uieaeure of succeus which atteaded thL-so injunctioua may, 1
think, in part at any rate, be attributed the declension in
FEVEB IN CMILDBBD.
281
the fever-rale at tlie beginning of 1884, a gradual decline
reBultiu<^, as I hare already sliowu, almost entirely from a
diintQutiou of septic influence, which froLa flrst to last is
as great us that wbich immediately fellowed the introdnc-
tion of sublimate.
The foct, nevoi'theless, vemnius thnt during the greater
part of the carbolic &nA Coudy era, owing to their tnutual
antagonism which tbey bad «?ery opportunity of exorcis-
ing, neither the perinimganate nor tlie carbolii; were, ho
to speak, allowi-'d fair play. The permanganate being
used in woak Hulution euifefed most severely.
But, in addition to tbie defect in the regulations then
in vojfue, auotber important consideration demands
attention as conducing to the decline in the general
forer^ratc during the later mouths of the pre-snblimate
period.
For, even had the regulations possessed no flaw, it was
impossible at chat time to insnre faithful adhesion to Boch
as existed, considering thnt no systematic instrnctions
wc-rf avttiUblo for the guidance of the nurses. And
especially doeis this become a matter uf importoitce in an
institution conducted on the Hues of the General Lying-in
Uoupital, iu winch the patients are all attended by mid-
vrives, and nursed by women who are undergoing a course
of two or three montbs' training with little or no previous
hospital experience. When the ease with whicb, in such
hands ns these, tbe chain of rigid asepticism is liable to
be snapped asunder receives due consideration, it is possible
to gauge the advantage to be derived from a systematic
method of working with u definite code of precise rules
Bnd directions, from which no departure sliould be allowed.
When I cnttTL-d on my duties as House Physician in
September, 18tJ3, no such method prevailed, and it was
then possible to predict with no little degree of certainty
how the patient*? admitted to any particular ward were
likely to fare by the extent to which the nurse in cbargo
had mafitered the details of antiseptic midwifery. At that
time temperatures of 104'' F., 10.i° F., and 106° F. were
2S2
PSV8B rK CaiLDDCS.
oomnoon incidents ; a normal tempera-tupc throughont the
puerpeTium was quite tlie exception.
But, as I liave already shown, dnring tbe early montlia
oi ISd^j clespite llie occurreuce of scarlet fever cases, a
very considerable improretneut iu tlie septic rate, and
consequently in the general fever-rate, occurred ; an
improvement which is so steady and persistent as to stand
out in strong contrast with tbe sudden rises and falls
which precede it, and which, even before the introdaotion
of sublimate, reduced the septicity and febrilitj to a
point not previously reached.
This was, I believe, in no small measure attribntablo
to the introduction at tha,t time of definite rules for tbe
guidance of the hospital sta:ff. As, during the &an)o time,
the details of antiBeptic treatment were one by one elabo-
rated, these regnlfttious advanced in completenesH. Their
syt^tematic adoption led to a great advance iu the ofBciencjr
of the nursing staff thtoughoufc the hospital.
Stadfelt, of Copenhagen, has expressed his btlicf that
" the hygieno of a Maternity depends leas upon its con-
struction aud upon ita age than upon the hygienic prin-
oiptes npon which it is directed, and on the perBevernncc
with which theHe principles are carried out in the duily
service." This opinion I emphatically endorse.
1 have shown that one of the most considerable improve*
meuta which took placs during the seven years occui-red
in the early months of 1884, before the sublimate era
dawned. I have stated that no structural idterutions had
been made during the whole of that time. I have recorded
the endeavour which was then made to systematize tbe
service of the institution upon hygienic principles. That
the endeavour has been attended with a great measure of
Buccess cannot be denied. For not only were Bcptic
illnesses, pelvic inflammations, unhealthy lesions of tbe
genitals, and I think I may add mammary inSammations
as well as case* of cystitis among the puerperse gradually
reduced in frequency aud virulence during the last phase
of the carbolic and Condy era, but at the same time cases
FKITEit m CBlLDiJEU.
of purulent oplitlmlroia auil t»f offeiisively discliarging
narcl, as well as of tbrush in children aod of abBcessea oa
the fiagers among' the curses, diminished in number.
Tliis can mean one thing and one thing only — that
septic iufluencu wasoutlie wane even before tlie sublimate
era commenced.
Having now considered in detail the decline in the
death-rate, in the general £ever-rate, and in the septic rate,
and also the changes which have been effected in the
eerrice of the hospital, I wonld present the following
general concluaiooB :
(I] That the gradual decline observed in the early
months of 1884, was brought about in part hy Bystemntio
attention to points of general hygiene, more pnrticularly
on the part of the midwives and nurses, and in part by
the progressive elaborntiou of details concerning the use
of the antiseptics employed.
(2) That the marked improvement which took place
in May of the Bame y^ar, was effected in part by the
substitution of auUliniHte fur carbolic acid and Condy's
flnid as the general antiseptics in uae, and in part by the
OODtiouance of the eame beneficial influences.
Having now ascertained what may be termed the
normal condition of the hoBpital for each of these periods,
&□ opportunity is presented of conHidering the effect pro-
duced by other influences. These will be discussed iu
the remaining sectioOB of the paper.
In the following section certain relapses which have
taken place Trill be considered.
niTicB w cHirnBBn.
885
V. Antineplicn vf the xuhfmate era; inea»itre/i tnken to
prevent deterioration of tite solution; infRTionty of
jialufrr nji ramjiurftl icith ttihliviate ; advontaijt of
antUepti<- over mere clfanltf viensure^ ; value of strong
tlouehe-solutioiui as compared teUh those of weak anti-
septic power and of no antisejttic powtr.
{Reee'ivei Doeenbn lOtli. ISSO.)
{Ahxtrnrt.)
The autiacptics used during the sublimatQ era ar<? coaaidcrod
in dvtail.
The iDHasurps iaVen to preveut d<'ti>rioriitiou of tlie soIuLioa
arc <]tHcu880tl.
It is jjotiited out that aeitlier more geuci-al bjpicnic mea-
8ur*>8. iior llio aoiiiLioii om|>li>yo(l (or tho hiintls. inBtriimcLts,
Ao.iior Ihi' lubricant, hiivc auffi*rt'(l appreriaMp viLi-iiiLiun, and
tliat tlie Holiitinn einploj'ed for waaliing and douchiug the
geniLnta has been the only variable eleuivnt.
Attention is also drawn to tlie fallowing facta —
(1) That as no change htis been miido in tho method of
aduiiuiBtcriug tlio doucho, its niechaiiical and ocbolic oCE<.>cts
have reinaiaeil unimpaired.
(2) Tbiil EU) the strcuglh and character uf the antiseptic
ogODt cmploj'vd iu the doQcLe-solutiou lia« bccu tho onlj'
▼ariabl« factor, correHpouding variations in the condition of the
lio^tt43 afford <-vidou<.'c of their coni)inrsttve valuo.
Such variations aw shown to have taken [ilare; for whvu the
sublimate douche-sulutiuu wiui reduced in strcngtlt, and again
whi-D tho ttublimate douche- solution was replua'd hy salufc^r. the
ideath-ratt" rose and s^pticoeiuia reasserted its inHuence. It is
reniari£ii.b]^ that the only thrw di-atha wbieh have oL-curred
from svptic poisoning during tlie \-a»1 &vo yea.n should bare
taken place in the two short intervals, amounting togelher to
less than tvelve wcvkH, during; which thoae Holutinna were UML-d.
The period during which Milufcr douehcn wore employed ia
coQiiidered in detail.
TOL. XXI II. 20
286
raVRR FN OHILCBBD.
It is pointed out that, as saltifer whb commonwd in the
middle of one tind diacoutiuiied iu tLe mitlilte of iLOother month.
Hie advance in tlie furer rate aad in thtt septic rate does not
allow to the full extent, when, ah in the forgoing ehnrtfl, all the
eases for each month are iaoluded.
Table IV. however, unmistiikably indicjttcB a retrograde
eondition of ilie hoHpital ilurinE the eight we^Vi* of salufer
<IoucIiinp a.s coinimred with the fortnight which ininiediately
preceded and which tmrnodintply fallowed. Compn.ro itlxo the
figures given iu Table IV with those fnven in the hwodJ colanin
of Table II.
Til is ahoWH —
(1) Tiat thr death-rate ros«, dntijrcm g^ptic poitOning.
(2) That the proportion of labours followed fty fevitr, and f»pt.
daily by septic fiver, incr^atrd.
(3) 'JViaf, in thefi^hrile oaf us, both the average duration and tke
average height ofthofvper increaacd.
(t) That both the central fever-rate ajii septic rat* advanefi.
Further, iu virtue uC Ihiii result, tl ie probable that had the
■obUiDatie not oiil^ of the douche. solution, but alto uE that
employed for the hands, iuati-umentfi. Ac,, aud of the lubritant,
been replaced by gtiltifer, iiud had ealuferbeeo used in all caat-s,
instead of in these ouly in wbioh danger wns leiist to bo feared,
the effeL't wuuld have been stiU more diiafitroiiii.
It is concluded —
Thai taliifcr is inferior to tiublimair na «n antiseptic ayent.
Iiicideatally (.■vidonev hue bvtu afforded —
(1) Of the value of douahfi-solutionit nf strong over th&te of
fMak nntiaeplie power.
(2) Of the value of antiseptic over mere aaeptie dottch*'
Bolafians.
The routine ubc daring puerpcry of weak antisniitie or of mere
aseptic douche-ftnlntiona is dep'"eeated.
By way of explanation the su^estion is put forth that septio
material eollected about the vulva may, in ailniiuiBtering the
donch'-, be carried into tlie iit-erine cavity, where, cscapiDg
iminedinte deBtruction, it is liable to become absorbed.
/( it conchidecl —
That -unlfga avch an antiseptic natiition be uaed ait iit eapahle of
ejftelttally and rapidlij de4(royin</ teptie vmterial, and uhIcmii the
ncnCR TN CmiTlBRO.
287
(oieriuti genitalt be carefully waniitd bc/orehajid tvUh a similar
ift/u/ion, the routine emplotfment of the dmteke dv-rin^ ■puerpery ie
liable, frcm the danger of nnavni^nhly introducing geptin maiiwial,
to he atieniled with positive, danger to tlui patient, and that under
etteh circuviirtaitceg H« tuechn-nical and rcholic ti-dvantages may be
mere than eottnterbalitnced hy Us want of eejma-deetrorfing power,
Suftinii'nt evidonee has been prodHoed to show that even with
tbiJ routine ub(> of etrocg Hublimate solution the danger still
lies ItiHx iu inerciLruLlism tlia-u iti sepHis.
It it, Ifierrfare, concluded —
That unle*f and vntil the maaijold aottretsa of eeplie infection
«an be ^aeed, and vHk eeHainly rf/wH loith ovifiide (he body, the
rontint employment nf the dovehe needs nc defence.
Beu-souH fur rojfariliu^t (liu Coiid;^ duucLe of the jire-ftub-
liraate period as aii element of dimger axp luldiiccd.
Finally, tho direct locul effect of the difforont antiseptic
agents on the tissues of the body is considered.
It is corit'ludijd —
That, though this qtitttion mnt/ hove c^ff'rcted to tovte- degrre the
comparative result* ohiaified htf carbolic acid and stilUmale, it
i^et net affect the value of the evidence which has been aJiluced in
tupport of the inferiority of weak sublimate andofsalufer douche'
telution*.
In this soctioii cortaiu relapses wliich faavo takcD place
since tlio iutroduotioa of sublimate will be dealt wttb.
It will be sliowu ttat one of tliesa relapses was definitely
(issociated with the Hubstitution uf Halufer for Kiibliniiit?
in the solution nned for wanhing and doiiohiiig tbo pntient»
Incidentally evidence will be afforded of iho valae of
antiseptic over mere cleanly menaures.
I proceed iirst to a consideration of the nntitiQptics of
lh« Hubliumte era.
Since May Ist, 1884-, eublimato solution (porchloride of
mercury 1 in lOUO) haa been employed witliout interrup-
tion for the hands, for instrnnienta, &c., and a eohition of
Boblimate in glycerin? of corresponding strength for
lubrication.
Throughout tho groflter part of the time sublimate sola-
268
wy:7V.it IN OniLDniD.
tiooB bare also been employed for wnehinjr miil doachinp
the patient, l)ut tbo etrength of those has varied.
At first 1 in 2000 solutions were need before and after
labour in tlio dolivery rooms, and iu the lying-in wards.
Owing, however, tu the freqnont inoidonco of cases of
mercnrialismj* and mave particularly to the fatal case in
wliich mercurial absorjition played so promiuenb a part
(see Fatal Case ft, p. 257), from 2i3t Septpmber, 1885, until
the Htli of tlie following month, the douche given in the
lying-in wnrds was reduced to hiilf the Bti*eugth (1 iu -1000) ;
but that in the delirery room, given botli. before and iin-
loedifltely after labour, remained the &amc ns before (1 in
2000) . Under this practice a death from septic phlebitis and
general pyieniia suuii oceurred (see Fatal Caso 10, p. 257).
In consequence of this from 14th November, 188-'), the
stronger douche-solution (I iu 2000) wa.s contiuned for the
first four days after labour, the weaker (1 in 4000) being
substituted only at the end of that time. Tlii^ practice
was coutinned until the end of the following June.
In July, 1886, owing tn the fact that the sublimate
douche givoii before delivery tended rather to constrict
the tissues of the cervix, it was omitted and Coudy sub-
stituted (perraauganate of potassium 1 in 8000). At the
sumo time the Bublimate douche given immediately aft«r
labour was increased to I in 1000 ; that given during the
firat three days of tho puerpenum (1 in 2000) and after,
wards (1 iu 4000) remained the »ame. If, however, nny
suspicion of mercurialism occurred, Condy was at once
substituted.
Such substitution has been rarely called for, more par-
ticularly since the beginning of 1887 when the douche
given immediately after labour roverfcod to the original
strength (1 in 2o6o).t
This practice has continued until the present time, ex-
cept for eight weeks in 1888 — from the middle of August
• S*> Dr. Diibin'^ pajn-r on " MKrciirUIUtii Iu L/ing-in Womtn," 'Obatct.
Trnim.,' vol. xxviil. IBHB. p. 281.
f Fur mtm nf uiiTi'iiiiiiliiiri xro ' Ubntft. Traiiii..' vnl. %xt, 1888^ |t. 320.
FEVBK IN CBILDIililU.
289
until tlie middle of Octobei- — wlit-u salufer solution (silico-
iluorido of syJa I in SOU = gr. xx to Oj) was used for
wushing and douching' tbo piiitiont'> both in the deliveiy
rooms and lying-iii wards, in nil cnses where tliere was uo
special rcaaon to fear infection.
But during this short timo two deaths occurred, tho
second being' from hospital gangrciio {son Fatal Caee» 13,
14, pp. 2(iO, 2(!1), with tho result that i>aluf»r wai>
promptly abandunod.
It is important to bear in mind that thronirhout tbewholc
of the time strong Bubliinate solution (1 in lODO) was used
for hands, instruments, &C-, nil d measures were taken to pre-
vent deterioration of the solution. Tht-'SB incasurca cull
for brief mention here I may say at once that, as ueithur
permtiuguiinte of potaatiium nor silioo-SuoridQ of sodii. nru
incompatible with porchloride of mercury, no considorn-
tioD of this kind need detain us.
Ag^ain, though for some time Coudy irrigation has been
employed before delivui-y, no important deduction on this
score need be made, for any dotorioratiou of iho solution,
which may have rotiulted from admixture with the small
quantity of glycerine used in preparing tho Rtock solution
and for lubrication, has beea guarded against by coa-
tiuuiiig the douche until ib returned unaltered iu colour.
Again, as regards the aiibliinate solution, evury precau-
tion has been observed to prevent cuuLamiutition with
soap (which throws down the [icrcbloridc us an insoluble
mercurial soap), or with bright steel or copper (which seizes
upon the metal of the mercury salt and deposits it in the
metallic state) . The importance oE preventing even a slight
dogroo of coutaTiiinRtion from either source was at once
rt-'CuguiHod. Very little contamination in virtue of the
atLunuated strength at which the solution itt used being
safiioient to destroy tbu whole of the subUiiiate, every
means was taken to guard against it.
The solution, therefore, has been exposed to no con-
siderable deterioration.
When fintb employed, however^ it was the prncliou to
290
rmrBB in cniLbniei).
make a concuntrutcd aqiiiHitiu sulaUon which miglit staud
bj for weeks btitoru it wus all used, aud thus become de-
teriorated by the alkalino coustituenls of the water which
bIowIj precipitate the mercury in the form of calomel.
But even thin wtia aiibsoquuntly obviated hy preparinjj the
solation for use directly from the concentrated solation in
glycerine as delivered from the cheiciat, am! xince the
begiauiug of July, 1636, by the additiou of a small quan-
tity of acid (Acid. Uydrochlor. dil. "iss to Hydrarg-.
Perchlor. gr. j). Whatever the amouut of deterioration
fnitn bhi» sourci: may have beou, it dous not toll to the
detriment uf the hospital iu the latter half of IStii, during
which time I can petBoually vouch fyr the frequent occur-
rence of such deterioration. I regret that 1 am unable
to trace the preciso manner iu which the solution was pro-
pared during the first half of 1885, and therefore cannot
fiay what relatiou il may have borue to the relapse which
then occarred.
Be this as it may, the important fact remains that for
the laal five years neither more general hygienic measnros,
nor the »oliition employed for the hands, instruments, Ac.,
nor tht: lubriuiiut, have Buffered appreciable variation. On
ihit; accoaut special interest atloohea to Kuch advance in
tho death-rato and in the fevor-rate, and to euch recur-
rence of septic illness as is associated with variation in the
etrougth uud character of the douche- solution. The solu-
tion employed for wo-ahiag the external genitals has bocn'
invariably tlio same as the douche. Tho bearing of this
is of cousideratlG moment, aa will immediately a])pear.
Now, apart from, tho antieeptic actiuu imparted to it
by the antlxeptic agent, there are two wayH in which tho
douche acts beiieBcially, of which the first is ujechanical—
a more flushing out uf the passages aiding the removal
of detached portions of tissue and of blood-clot ; the
second, ecbolic — tlie tt-nipernturo at which it iti given
(115" P. immediately after delivery, and 110° in the lying-
in wards) »tiutulating the utei-iue muscle to action, and
thereby preventing the forojation and assisting the expul*
rZVKV. IS CHILDBED.
291
sioD of retained products. Thig, however, woald take
pUice equally whether mere sterilised water, or aalufer, or
sublimate solution lie employed.
It ia, therefore, reasonable to conclude —
(1) Tliat as DO chaage ha? beea made in the method
of odmiQistoriDg the douche, its mechanic'ftl and echolic
effects hftve reniained unimpaired.
(2) That, SB the strength and character of the antiBeptie
agent employed in the douche-solution has been the only
variable factor, corresponding varintions in the condition
of the hospital afford evidfmce of their compai'ative valne.
I shall now show that such variationa have occurred.
The charts show tliree relapses in the septic element —
one in the first half of 1885, to which I have already rC'
fcrred, a :*econd at the beginning of 1>S87, and a third in
tht' auttimn of 1888. This last, which appears the least
important, is for reasonR which I shall presently explain
the most 8o. Two of the oases of septic poisoning proved
rapidly fatal during this rclapsf, and on that account the
record of the fpTor was cut short early. A aimihir fatality
took place in the antumn of I88-'>, which for the t^amu
reaiion loft hut little truce ou tho fever chart.
Now, it i« a. remarkable fact that the only three deaths
from septiciBinia (kar Fatal Cases 10, 13, 14) which have
occurred during the last five year.s should have taken place
in the two nhort intervals, amounting together to less than
twelve weeks, during which either subllniate sohitiun of
diminished strength, or salufer were employed with the
douche. For, oven after allowing duo prominence to the
fact that in one of the cases sublimate alone was used,
and that ^ev€ro traumatic influences had boon brought to
bear upon it, the difference in the death-rate is very strik-
iug. It is obvionsly an unfair to include this case in ono
category as in the other. If it be excluded, two deaths
from eeptic poisoning will bo found to have occurred in
94 oases douched and washed with weak sublimate and
aalufor nolntions, agaiiuft one iu 2026 cases iu which strong
sublimate solutions were used ; and, if it be included, three
fSV%R IN CBILDSED.
doathB wUI be seeo to have taken pince from Reptic poison-
ing among 114 o&bos admittod vhilo the weaker doiioho-
solutions were in use, against no uuch death in 2036
admitted when the stpoiiger douche-solutions proffailod.
"With regard to the first of these periods, during wliich
the Bublitnate douche of diminish^ed strength waa emplojred,
the eWdciice of the relapse reats entirely on the single
death from septicaomia, it ia iiot supported by the occur-
rence of other Reptic cases. But as 27 patients only were
treated in the same way, tliis result is not surpiising.
The second period, during which the salufer douche
was employed, calls for more extended comment.
I have carefully analysed the cnses adroitteii from the
beginning of August till the end of Octobei" — 136 in all.
Of tlioae, 77 were washed and douched with salufer; 10
others distributed about among Lhem, and iu which from
tlie character of the labour there was special reason to
fear the introdnctiou of septic material, were duaoUed
with eubllmate entirely.
This inveatigatiou shows — ■
(1) That during the eight weeks of salufer doucliiug
two deaths occurred from septic poisoniug, unH, though
severe traumatic iuflueuccs had been brought to bear in
the firdt, no snch allowance can be made in the case of
the second which followed n normal labour.
[i) Tha,t duriug the same period three additional cases
of septic fever occurred, whereas during the first half of
August, i. e. before salufer was introduced, and during
the latter half of October, e. e. after salufer was abolished,
no such case occurred.
(3) That some of the teiupcrature charts during the
salufer period were beginning to revert to the type wit-
nessed during the carbolic and Condy era, iiud that the
longer the salufer coutinued in ubo the more frequent aud
more striking became euch iusitaucea.
Tliese facts to my mind are of distinct siguifioance.
That this retrogreasion does not Gud marked oxpression
in the foregoing pyrexia cbarttt may be readily accounted
FITBK IK CHILDBED.
298
for, when it is remembered tliat salufer was einployetl for
ciglit weeks ouly, and was commenced iu tlie middle of
one nod disooutiuued in the middle of anotlior moutti, with
the effect that the unsatisfactory salufer caaea arc (whi;n
the general fever-rate and septic rule are cxprcesed as in
tli6 chart for the whole of each month) diluted by the
satisfactory sublimate cases.
■ Moreover, in eftimating the eoropar&tire vftluo of tho
Biilnfcr and .sublimate douche, the fact muet not bo lost
eight of that in those cases iu which septic iufoctJou was
dreaded suhliniato was alone employed. It is but fair to
conclude that had thlu precautiun been omitted, the com-
puriiion would have been still inure pronounced.
7\ihle IV (p. 294.) seta furth tho eompurative result of
the BBlnfer and sublimate douching upon the ISl> cases
admitted during tho three mouths.
ConipOrro aUo the figures given in Table IV with thoso
given iu tho second column of Table 11 (p. 203).
This shows —
(1) That the death-rate rose, and from septic poisoning.
(2) That tho proportion of labours followed by fever,
and especially by septic fever, increased.
(3) That, in the febrile cases, both thoaverugu duration
ajid the aversgu height of the fever iucreaoed.
[4} That both the ^ueral fovcr-rate and septic rate
advanced.
1 have already stated that it was in the antl»epbic of
the douche* solution only that any tLlteratiuu was made
Iu virtue, therefore, of this result it is probable that, had
the sublimate not only of the doucho-solutiou but also of
that employed For the hands, instrumentB, &€., aud uE
the lubricant boon replaced by sulufer, and had saiufor
been used iu all eases, iusCi-ud uf in those only in which
danger was leant to be fearoJ, the effect would have been
still more disastrous. _
It is concluded —
That liulurerisiuferiur to aubliuialc as an antiseptic agent.
luuideuiully evidence bus bet-n ulTurded —
2d4
riVBB IN CHILDBBD.
a
s
a
K
I 3
^
5^ ?5 S 8. I: i
„-, ^., » S iS ■
3 n 3 I § "o « g «
"•"N JN PS ti ^ ^ "■ *9
s s *- E s
i ? S S S
g o ^ g &
r
•at
i
o
&
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5
S) Si
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a
e
■S
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PVTRR IN CHILDBED.
295
(1} Of tlio yalue of doucho-solutions ot utroug over
Ihuse of weuk autiseptic power.
(2) Of the value of antiseptic over mere aseptic UoucLe*
solutions.
Kecogui(;iiig the mechauical and oobolio advnnta^cs of
the douche, 1 was seriously couaideriiig the ndvisabilitj
iployiiig water merely sterilised by boiliog — of usiug
aseptic in place of au antiseptic soliitiou — for doucbiug"
purpoHea ilariDg putrpery. But lu virtue of thu rBsult
now obtained' — whicli I was very far from auticijiating —
of umployiug suUibioDs of dimiiusKed Eintiseptic power,
ftuch an experiment docs uob aecm justiliablo. Kor if
solutions of diminished antiseptic power prove inferior,
stiLl luvre would Boltitions of no antiseptic power (merely
aseptic) nhow to disadvantage.
And, considering tlie results which have bi>cii obtninod
when tho douclio as a runtinc uieaaurc hatt boon discarded
altogether, I am forced to this conclusion —
That, unless the solution used be not only aaoptic, but
at the game time aiiliseptic and strongly so, thej rouline
employment of the douclio duriug piierpery is liable to be
attended willt positive danger to the putient, and that
under .inch circum stances its mechanical and uchulic advan-
tages uiay be more than counterbalanced by its want of
sepsis-dcfitroyiug power.
I am of opinion that this may bo explained by the fact
that in the introduction of the pipe, even whon an al'tempt
is made to cleanse tho parts boforohundj septic matter is
Gtill apt to lurk about perineal lacomlionB and tears of
the vulva, and may be carried by this mtmus from th«
lower part of the vaginal strait to the upper [)art of the
parturient canal, where, escaping immediate det<tmction,
it ia liable tu become absorbed. i*
I wonld, therefore, nrgfr—
(1) That such an antiseptic solution should be used oa
is capable of effectually and rapidly destroying septic
* 1 haw alTMdji Kltmiii by vxpvriiHuut thiit (oluliuiiK iatiudiuwil iiito Uic
v»giii> sia] rMch ik* utcriue a«ilj. 'Obatrl. Tna*./ vol. ttt, 1888, p. 806.
296
KHVEK I'S CHILDBED.
muterial, and that tlio exteraul gc-iiitals tidoiild bo
fully washed beforehand with a similar sulutiou.
{'i) That, failing this, the; doucho as a routitio moabure
had far better l»e discarded daring puerpery.
It will be obseiTed that these remnrks apply solely to
^(ter^itri/, and to the rtiuUne utte of the douche. I would on
no account omit the routine use of the duucho during
lahattr, nor counsel its nt-gloct iu Cfirtmn caaee uftcrwards,
even when the above precautions are not carried out ; but
1 would strongly advise that, whether given as a routine
nicasure or not, it should be used attd used only in accord-
nnce vrit'k ancli precaiitions-
It may be urged agniust the routiuc use of tlie doacho
during puerptiy that no ueceBsity for it exists in tlio
uiajorily of lying-in ca-ws. To this, I aaswer, Eveu so, it
is the minority of such ciii^es which benefit by the uieaaure
applied alike to the whole ; and it is thii diRiculty of de-
ciding beforehand which cases will fall into one category
aud which into the otlier that preveuts it from being
applied 8o!oIy to the minority,
I have Kbowii th»t tbi» minority proved &n undetermia-
able factor during the ealufer period; and aoit must always
happen while patients are beset with 50 many possiblo
Bources of infection as exist in a lying-in hospital. Only
wbou these sources of infeetion can be removed is it snfe to
UiHpense with tbo contiuuaiico uf the douche.
I haw produced Huflicient evidence to ehow that eveo
with the routine use of strong subEimate solutions thb
DANGKK SriLL LIES LKSS IN MKRCURIALI8M I'AAH IN SKKSIII,
Therefore I cont^Uide —
Thatj unless and nntil the maaifold eourcea of septic
iiifcutiou can he traced aud with certainty dealt with nut-
Kidu the budy, ihu rouLiu» empEoyuivnt of the doucha.
needs no defonco.
Reverting now to the douche-solutions of the carbolic
and Condy era, it may be remarked that a like criticistn^
applies to the Coody douche which was used during puer-
pury as to the sulufer. The Hiiiglu carbolie solution which
RTIR Dt OBILOBBD.
29:
was used immedifitely nfter labour, b^ing, so to tupoak, a
concentrated Bolutioii, Buffered Irtlle dctcriofation in com-
parison i\'ith tlie uiTicli more attenuated pennatigunato
solution wliicli was used for tlie doiiclie daring |iuerpery.
This, for reasons which I have alrt-ady given, was more
oftoii than not reduced to at best a very we»k antiseptic,
or to a merely aseptic, solution.
Finally, there ia one further consideration which calls for
mention in estimating tlie comparative value of aiiti&cptic
agents. 1 refer to the direct local effect of these agents
00 the tissues of the body. With regard to the carbolic
douche employed immediately after labour duriug the
cnrbolic and Condy era, it may be urged that, entirely
apart from their comparative antis«'ptic value, the carbolic,
being far more irritating when locally applied, was more
liable thnn the sublimate to alfect injuriously tissueH which
were already in a more or less damaged condition, and
to this fact may be attributed iu womc mt'aaure tho Hupe-
rior results obtained when tho former was replaced by
tho latter. To what extent Ihia may have affected the
result it is impossible to say. No aucU coue^iderntinn,
however, attaches to ihechnrgOB which were subsoqueutly
made in the douchc-soIutiouB, for neither permangimato,
nor weakened sublimate, uor »ialufer ai-e us directly irrita-
tion to the tisHuea nti either the carbolic or the strong Bub-
limato Boliitions. This conBiJeratinn, therHfore, dooa not
nffeel the value of the evidence which I have adduced in
support of the inferiority of weak sublimate and of Halufer
douche-sol utions .
General Stimmary tif Part I,
(1) By a study of the f-cni-^ral f«v«r-ratr, of the septic rate
and death-rato. aLd by au aualysis of the iiiori' severe caaes of
illoeaa. tlio state of Uie hospital liaiibi-oa determined, and varia-
tions in itJi condition hav*? been pwiiitoil out.
(2) The servicv of the hosiiital and the cbangos (both of a
goncral hygienic imturv itnd iiIko Huch us pertain more (inrticu.
larly to autisepti««) which wore cfTectod, haw bevu drscribe<l.
296
rXVEH IM CaiLDBKD.
(3) Tbc coincidence of tbesp cbanpoa with Tariations in fbe
oouditioD of the lio»(jiUl biut b«c*u truixit].
(4) npou these dnti it is uoacluded that tx. gradual improve-
ment romiltc^d, {inrtlj' fr^m ^jstcniatiG nttoiuiou to poiiita of
general Kygifne, ami jiarllv from jtractire in dfatiii^ with the
ontiacptica used; and that fi furthcir improvement wnaeffect«l hjr
the eiibstitutioii of kubUmatc for carbolic n^'id aud Condy's
fluid as the gpueral aotisuptic in usf, but that retrojfrMaion
nocurrt^d both wbtu tbt; suhliitinto tloucho-solutioii was r^uoed
ill atn^n^th, and a^ain when the sublimate of the doticlie- solu-
tion wa8 rcjdaccd In- wihifur
(5) In virtot- of this result it ia contended that as an anti-
septie Hytmt suhlimHtc 18 supvrtor to carbolic acid luid Condy'g
and also to Halufer.
(6) Pinally. thut aa the antiBcptiu of tho douche-sohition was
the oulv element whieh Biilfered variulion, the value of strong
doticho-BolattouB compared with douclie-aohitions of weak anti-
»c]iti<! jMiwor, and, aforlinri, the viUito of antiaitptic compared
with mor^ UKuptic duuche-Holutioiiii is rendered obvioua.
Dr. Braxton Qickb said that it was by giich pauers as ihia
that wf- should soraf> dny arrive at th.* ftolulion of tee cause of
puerperal troiibli-s. ll was a queatjou which nutumll/ intere«t<.-d
biin tniieb. for at the Duhliu uieeliug of tlip British Association
many yeara a^o he had read a paper " On the Uso of AutiDcplic
[Jturiue lujeetioiis after Labour with Offensive DiachareeB, as n
Ruly of Prtiiitici'," On tbat oti^nioii he wiis fiatouisheu to find
this ruleupposod bv the laUt Sir JumeH Simpaon, who viewed with
Aiixioty such trofltmont ; tvt that time Dr. Hicka rejoined that he
would rather have rlean water thiui *itiultiiig disdiarj^L's. Ho
was therefore ninoh gratified hy the resiiltH hLowu in the paper.
But be tbouRhl earo wan necessary in using the injections; and
also he alluded to iiuotber risk, aamely, the effect of much
Miovement of the patient, whieh wiw liable to load to cxjjanBion
of the thorax, and thus to " insuck," whereby irritating material
could he drawn iu tbroiigli any openiiifjr iu VL-innor lytnph-spacoK,
tiB Dr. Hicks had pointed out iu ;i, paper before the Misdical
Society and tii the 'American Journal of Medical Scionees.'
Dr. Ha,yeb reL'retted thai Dr. BoxiJI hud nut included in hi«
r^ipurt tb<^ period when he mid Dr. Fancunrt Barue» were phj-
eicians at tlitf bospilal. Thev took up the work in Septen^her, 1879,
aft«r the complete ruorganiaation of the hoapital. which he luid
mVER IN CHILDBED.
299
tblargc sbftrc in bringiu^ about. PrcviouB to the ri^or^auiiiatioii
b« bail !Ltt«Dipti>d to ititnidiiCH name oiitiseplic tui^asureB, but
tber had been streououalv op])aHed by tbe authorities and some
u( ah collea-guos. lu lyVtf, uiiou tbe niO|»eiiiiig of Ibe bosfiital
uudcr an tulimlv uew s^MtJi-iii, tlif HTjtlKfiJt.it; rtiJi-s otlojityd were
tbose drawn »p by Sir Josei>h Lister. Absolute pbeiiol waa the
autiaeptic asod — 1 in 20 for bands and iafitnimeiita. and I in 40
lor vaginal injections. Their results were highly satisfaptorv.
Ho hiid had only oiic case of Rerious illness, and that vait nn
inntauiM: i>f supticiBuiiu iiiducL*d hy niiqiio6tii.>uablL- disve^rd of
tbe antisHptic rules. Tbe jjatient. however, recovered. Dr.
Httve.i had adopt+^d vaginal injeclions with 1 in 40, or 1 in HO
cNirbatic acid in every case for tbe first week after labour. J>r.
Barut^'M used no viigiiial iiijt!ction»,iLnd Uh cnaes dtdeqiialK' wl-II.
Hu was ntnink wjtli this at tlu" tinie. He now tUoii^dil tbitt
vagiual douching after labour as a general rulewiw unDt-cessarv-
^indeed, wilh the onlinary run of nuTMw it was dan;efiToii.« Sunn
nurses were earelesK about the cleanlmeHs of the tulies, &e. Ho
had therefore given it up, unless the lochia became offensive, or
tho pftlii;nt elbowed Kymj^uuiH vi illness. In auituble coses he
strongly advocated intra* uterine injectiong. but to he of value
they flhould be eopiouB, and the whole iutenor of uterus fre>>iy
bathed. For this [mr|)otie hie own tube, giving (orfcli a is|iray,
wan very iiatisfitctory. He bad quite discarded nil diaperx, and
used now antiseptic absorbent wool, such ae that impregnated
with ft&licytic acid or sal aleinbrath. During labour all va^nal
exaiiiiuationtt ebould be made with abeolutfly cle&n h&udit and
earbolined glycerine (1 in 15).
Dr. Leith Napieb cougriitukted Dr. Boxall on bia elaborate
statistical record. He tbounht that oompamtirely few men
vould have undertnLen Hueh hLlmrious inquiry with so Hiiiall a
prospect of practical result. But Dr. Boxall had attuiued prac-
tical resulta. Ho hitd shown that, ut leaBt bo fur as lying-in
hospitalu were coUL-eniod, iiiorbidity wus greatly le&tiuned by the
routine UM of mtrctirial douching. Previous Biwakers, especi-
ally Dr. Hayes, bod auticijHbted mauy points about which Dr.
Napier held strong couvictiouji. Tbere might be geuural agree.
m«nt ibat routine douching wau n«)e«Hsary or at least advisable
in lyiug-iu hospitaU whero large numbers of puerperal women
were aggregated, but he tnurh que«iioned if the same iii«uun>ii
were required in privftt« ]>r«*?tiee. He (iskwl ©r. Boxall if he
believed that mercurial duucbiug wae an absolute preventive
of neptictemia. If there was no abnormal &igu, did not Dr. BoxitlL
admit that the- poraiblo and undispntLHi risks of douohing,
es)>ociaIly if Hyrinffvs were used, were greater Ihuu the nak of
waiting till indii^tiona firoBo-' Tbe ratio of possible miHcbief
fironi H general employment ot mereurials in non-septie inuiea
must not be oTcrlook«d. Fur several yean Dr. Leith Ifupier
soo
yKVNB IN CHlLDBtD.
hiul 8_rstfiiiiiticiilly ordered douching, but ho had for ROme con-
Bick'raltle tiniu abcindoned the [)nu!tict<! ualeaa iucreaaed tempcra-
tur« uud j>uUt' or local aigiia of toxteniia iitoae. lu iiiilntnuutoiTJ
jdiei'jjenti i;ii.-sc?t Ert-quent dutiililti^ wtiH Imrtriil ; riLgiuiLl supposi-
tork'aof ioJofurm WL're]iryfurabk>. Merfurio [wrohloride was.oQ
the wliolc, the best antiseptic for the purpoau at preaeot, tut it
bad nian/ objectioos. OE late lie iiiwJ u»ed freoline, which
seemed to aaswer well ; it bad the advaotagc of beiue non-
poisonous. He trusted that Dr. Boxall would eoutinue biaworb
ret^iLfding the miTitB of ihu rarioua antisoptic a^ntu, and that
eventually some other and better drug would be found to roplnov
the pei'c bio ride.
Dr. Walteie Okiffith uiid that tUo [juiistion which would
interest the yreat bulk of practitioners of midwifery' waa. How far
were ihene preeautions, which had been proved beyond poMi-
biJity of doubt to be ueccweary to reiidc-r aaic the iionSticuifutii
oE women oollt^ted together in lyiug-iii wards and L>ospit:ils, to
be adopted in tbo ca»L< of liidividuala uoulined separately id their
own houses ? It was obvious that the riak was greater in lite
Eoriupr, but that the difference was uot due lo a differeuti? in
kind 80 uiucL as in degree. It would lio invaluable, but a very
difficult mattor, to oLitain such tables as those compiled by l>r.
Uoxall of the latter class of cases in unmbers suBieioiit for oom-
[mriijoii. If the hauds of the attendant nnd Qiir«e, all tbo in-
Htruuients and appliaticcH, fttid the patient herself, were kept
clean, aJl routine douching could be done away with On the
other hand, most people aeeustoiued to habits of cleaiilineas pro-
teiTcd II douche ol some kind nij,'htftud moraiug for the first few
(laVH afLi'r lubour.
Dr. C01J.1NOWOKTH, as a member of the present staff of
visiting physicians at the Qenoral Lying-in Hospital, oxprc8»e<l
hie j^ralefii] tipprecifttion of Ihe valuable paper to which they
had lisleued. He (Dr. Cuiliugworlb) came on the s<*ne at a
timy when the victory over puerponil inteclion in that bcnpital
was already uearly cotuiilete. He could therefore take no cnxlit
to himself for the eicellence of its preseut condition. Iiideed, a
fllightfy retrograde movement had followed Uia appointment,
for, in his desire to find an antiseptic which ahould be ft» efficient
as corrosipo sublimate aud yet noii-poiHonous, lie had thought it
his duty 1« iiitroduee ealufev at the liobptttil iui a eubiitituto for
corrosive aulitliualo in douching. Salufev had been most highly
spoken of by a well-known professioikal cheniisi, who had tnadd
a, series of ciperiiiieuts to determine its value as an autJseptie,
and had L(*n reported by Mr. Mayo liobson, of Leeds, to answer
well iu ordinary surgical practice. Notwithstanding this double
recommendation, they began to go a little wrnng fjom the time
of ila introduction, aud at the cud of two luouthii bo did not
feel justified in continuing its use any longer. He therofori} r«-
I
I
I
7EVEB IK CBILDBBD.
801
turned to the sublimate doucting, with the result that the
patients at once began to recover (uore aatisractorJly. He looked
foward to & time when, witlj increased knowledge of the means
of combatiugsejrtic infectiun.douirbing could he Bafely aboliKbed.
At present, however, in hospital practice it Beemed essential.
Id pritate practice he did not thicK it was bo netfBsary. AJid,
even as regards hospital practice, it must not \ye forgotten that
inthelyiDg-iDhoBjiitalBof Bostoiiand New York, the best results
were liot oht&ined udUI the douche was dclibemtcl; abandoned.
Revcrtiiig once again to the disaitpuinling resultg of the use of
ualufer, h(\ might say that a pOHsible cause of failure woe the
clogf^iD^ of tlio vnlrea and apertures o£ the appai-atus hy the
salufer, which was tJirown down from the solution in I'onsid emhlc
quantity. In reference to the use of an absorbent subsUtuti; for
the ordinary diaper, ho could apeak most highly of wood-wool
pads. They were euperior, lu his experience, to pads of
aliBorhent wool, and were now regularly used at tie General
Lying'in Hospital.
Dr. BoxALL. IB reply, thanked tliu Societr for the uttcntJon
which bad lieeu given to his paper. He would address himself
briefly to the many iuipartauL points raised by the several
epeakers in the di&cuasioa. He mi^^bt add to his remarks that
the intra-uteriuc douche was rcaervcd for cofies in which th«
hand or eoine iostrument had been introduced into the uterus,
01' in which the foetus wa» maoeratcd or decomposed, or, agaiu,
in which clots or pieces of membrane were retained. In such
caKS it was his invariable practice to employ it, both in hospitaJ
Md in private, iramediateiy after hibour. But during pucrpery
he introduced the tube intu the utorue only in exceptional cases,
and in these be usually employed a soft rubb4>r catheter or piece
of elastic tubing. He felt confident that much harm of one
kind or another might be producod by the indiscriniiuatc use of
the uteriue tube wliciiever the lochia tiecanie offensive. For,
though these conditions were oflori aasoeialed, on the oue baud,
offeQsivenesa of the lochia did not neccsiarUy iiidicate Geptic de-
composition, while, on the other, septic dccomposilion might tak«
plact) without it. If, however, there was good reason to susp+'Ct
the occurrence of Bcptic dccompoiition in the parturient tract, ho
would proceed seriatim and i-xuniiDc first the part« about the
vulva and lower vaginal strait (for it is in that situation that
decomposition most frequently occurred), cleanse and wash
them thoroughly with strong antiseptic solution. If that Failed
to reach the root of tho mischief, bo would next douche the
TOgina; and only after this had l>ecn done would he resort to
iutiiL-utenue douching. In this nutnncr tho risk, which he
felt was very real, of carn-ing septic mutter from the vulva or
va^inib into the uterine cavity, and thereby increaaing the mis-
chief, might be obviated, or at any rate dimiiiishcd. Whether
VOL. XX5I). 21
aoa
FBTEK IN CaaDBED.
the iitcrini} ttibo he uecd or not, b« voulcl, vlicn be hud rooBon
to ausptxt ihnt dccoin posit ion had takeu place, use a stroi^
Bolutiou (percUloride of inenrurv i in lOOO), aud pleotjr of it.
He considered that, in such a oase, it wua preferable to bring
the full forcv or the nutiHfptit: ut ouot; iutt^i play to running
the risk of baTing to repeat tlif prucetta. Wheii th« paper
was written, I>r. Boxall was not itwuiv thiit for u. time iLft«r
the re-opening of the hospital iit 1870 carbolic acid, and
carboli<; aL-id alonr. was used, and that the vagiaal dourbe
was only occasionallv resorted to during pu^rjierj. Hut tbis
fact is importtkitt in ni-tue oE the etnteumnt of Dr. Ua^cs that
during tbiu time there was less illness than dnring Iho aubsv*
quent carbolii' and Condy vm, when tlie douebe wus <>mploy<xl as a
routine measiire duriug puerpery. This, however, wts preciwlj
what Dr. Boxall would hare anticipu,t«d , It bore out the con*
tention eipreased in the paper, that the Oondj douche utied
duriug puerpery, owing ju great i>art to tho rcdoctioa of the
pemianyBnute by carboli<.- acid, possv&scd at bust hut weak aoti-
septii- power, and that under HUeb conditions more harm than
good resulted from its routine employment. In private pructico
Dr. Boxall invanaUty ci»)>!oyed lor tb« bauds, &c., subLinutv
solution 1 iu 1000 (wbteh be found far less irritating tlmn car-
bolic acid Hululion 1 iu 20), iLud •! sublituate douobe I in 2t)0O
during labour aud immediately after delivery — reserving tbe
intra-uterine douche for such eases ».» thoee indicated above, and
giving as a rule no douehe whatever during paerjjery. He
lookod forward to the time when the use of the douche could b0
similarly restricted iu hospital practice ; hut it was eo difBcult to
foresee the dangers to whitrh individual patients were inhject«(l,
pacticulttTly when ministered to by unskilled midwives ajid
Dursea, that he could not at present advise its omission. Some
such selection vaa attempted duriug the salufer period, but it
was found impmcticable. It waa the rule at one time to iusctt
an iodoform suppository into the ut«rus iu all ciLses iu which
intru-nterine irrigatii>n had been reaortcd ta^-uot as a substitute
for, but as au acu>ssury to tbe douche. As far as; can b«
gathered from the ti^iuperature charts, uo advantage waa gained
by using tbem in this wtiy. Dr. Boxall wa-s not diapused to look
upon tko intruductiuu into the uturuu of ua iodoform lx>ugie as
an efficient substitute- for the iatra-uterine douche. The pre-
oautious which he advocated in the use of sublimate vere iodi-
OHted in his pa]iGr on mereuriallsm. At Icftst as far back as
1882, absorbent pads of cottou or of wood-wool had been used
in place of nupkins for hoHpital cases, and in private Dr. Boxall
invariably recommended absorbent cotton. This pad wis burnt
aft'er use; it cost no more than the washing of n napknn, and
afforded greater comfort t« the patient. Some yeara ago Dr.
Boxall made, at the suggt^stion of I)r. Cbampneys, an inrestiga<
rKVER nr CniLDBED.
303
t!i>u Into the compiLralive [lower uf iibsorj>ti«ii |)UitKi-8»i.'<l hj
wwxl-wool auilvottuii. Hi- found that both for whIlt au*l for
blood the sample of wood-wooL wia ioferior iu this respect to
cottuii. The faculty- for abaorptiou (inssessed hy ditferont
samjiL^s of absorlient ijottou varied very oouBiderably, ami it
waj qiiiti! possible tliiLt tbe wood-wool wlikb wtia uuw iiiiinti-
i'iKH.urL'd wiis aupunur to tbut wliicli wna Srsl put ink) tLo
market. LuBtly, witli regard to the utrwogtli of the aubliniu.te
solution ueceaaary to cope with sepsie. Dr. Buxall uonaidcwd a
aolutioaof 1 in lOOO sufltuieiit auduion: tlia.D suQicttiil to destroy
aiiy septic iiiaterial willi wbich it cam« iuto cuiituet. Hv ttlso
Lwliervd that tiuLittioiis of less xtriiiigtb won- sullicitmt in many
CIUC8, b«cn.ui»e, iu addition to the eepsia- destroying jwwcr of the
solution, a very potoat power of the same kind was possedsfd
by Iho tiflsues of the body; and, where it was a qneiilioii of
attacking aeptic matf-rial in the paasagcn, thint iniiiit be taken
iuto aecouDt. It was in tliose cases only iii which the tissncb
(either IocbHv or as the result taav be of trauuiutiiim, ur getie*
rally where nial-nutrition prevailed) had lost the power of ronist-
aiice, aud had gone over, as it were, to the side of the enemy, that
the whole stri'ss of preventing sepsis wa.» thrown upon iho
uutiaeptie luHiHuri's. This diffleiiUy in jL^imj^in^ the remitting
power of the tiseues, added to that of determining tlio rieliH of
infection, in individual caacH, entailed tho neceiwity of neiug^
BtroD>f «olution« iu all ea»e» iu order to prevent itepsiK in a eer-
tain proportion. On this qu^stiou. however, Dr. i3usall spoke
with »uine diffidence at the present motnent. an lila intention waft
to nay iiioro on the Rama suliject in a Ruboequeiit piirt of thi>
|>aper oa which he wu etUl engaged.
II
OCTOBER 2md, 1890.
Alfbed L. Qa-Ubiit, M.D.J President, in the Chair.
ProBBDt— 44> Fellows and 4 YUitorg,
Books were presented by Dr. Carbouelli, Dr. Currier,
Dr. Pinzaui.aud the Council of University College, London.
William John Gow, M.D.Lond ; Alfred A. Kanthack,
F.R.C.S., and A. Ajlmer Orr, M.A., M.B-Oion., were
udmitted Fellows o£ the Society.
The following gentlemen were elected Fellows : —
Richard Ackerley, M.B., B.S.Oson. (Ashburton) ; Arthur
Norman, Boycott, L.R.C.P.Lonil. {Hugeley] ; AVitliam
Ueory Laurence Coupl«ud, M.B.Caatab; Charles David
Green, M.D.Loud., U.S. (Upper Edmonton] ; Darid
Berry Hart, M.D.Edin. (Edinbui^h) ; Harold Low,
M.B.Cnntnb.(Sytienham); Harrj' Burgess OBburn, L.B.C.P.
(Claplmm) ; A. W. Mayo Rotsou, F.K.C.S. (Leeds) ;
John William Taylor, F.E.C.S. (Birmingham) ; Walter
Tyrrell, L.R.O.P.Load. ; Samuel W. Wheatou, M.D.Lond.
(Clapham); and Edwin Francis White, P'.R.C.S. (Putney).
The following gentlemen were proposed for election : —
John Dysart McCaw, F.R.C.S. (Kfist Finchloy) ; Hugh
Jones Roberts, M.R.CS. (Penygroes) ; and Henry
Bartlett Shillingford, L.S.A. (Pockham Rye).
VOL, XXXII.
22
8oe
THE DEATH OP DR. J. MATTUEWS DUNCAN.
A VOTE of oondoleace on the deatb of Dr. J. Matthews
Duncau, past Fi'oaident of the Sovietyj vras put from tbe
Chair, in the following form :
" The President, Council, and Fellows of the Obste-
trical Socipty of London take the earliest oppor-
tunity of offering to Mrs. Matthews Danoan
and family the expression of their deep sympathy
in the great loss they and tbe profession had
BQStained in the recent lamented death of
their highly distinguished Honorary Fellow,
Dr, Matthews Duncan."
This vote was carried ananimoualy.
KIGHT OVARY
AND TUBE
BLOOD.
DISTENDED VHTH
By William Duncan, M.D.
UTERINE APPENDAGES THE SUBJECT OP
TUBERCULAK DEPOSITS.
By WaiiAii DiTNOAM, M.D.
UTERUS WITH PRIMARY CANCER OF THE BODY
EXTIRPATED PMB VAGINAM.
By WlUUM DUHCIH, M.D.
807
DELBASTAILLE'S SPECTJLUM A GLI8SIERES.
By Albas Dosan.
This instrument haa been described and figured in the
* Contralblatt fiir Gyuafcologie,' No. 18, 1890^ p. 324.
Mr. Duraa stated tliat be had frequently used it^ and found
tbat it W03 a good foi-m of apeculam in mnuy respects.
First, it w(w mode of metal and readily cleaned.
Secondly, it wns of the form of Ferguason'a instrument —
the best for geueral use — the easiest wherewith to get a
good view of the cervix uton. Thirdly, the sliding arrange-
ment overcame the chief disadvantage of Fergussoa's
BpeculuiD. Dr. Delbastai tie's instrument was split into
two Halves along its long axis. By sliding the upper half
a little backwards, after the cervix had been brought welt
into view, more room oould bo gained for using a volseila,
sound, or aay long aud straight- handled iostrutnent. A)l
who used Fergusaon's speculum recognised how incon-
renieut it was whenever a long-handled instrument had
to be employed. Dr. Delbastaille's speculum could ateo
be ueedliko n Sims's " duck-bill," aa a handle was made
to screw on to one half of the metal tube. This arrange-
ment was very convenient for inspection of the clitoris,
vestibule, meatus, and anterior vaginal wall.
TUBAL GESTATION REMOVED BEFORE
RUPTCHE.
By G. Ernest HcRMAtf, M-B.
Thb history of the case is puhliehed in the 'British
Modical Journal/ beptember 27th, 1890. The points of
808
PELVIC OE0AN8 OF A PATIBST, ETC.
intcrost in the epeoimen wcro (I) its remoTal beforo
rcplure ; (2) the pa^tiont had been pverionsly cured by
operatiou of a gestation in the other tube; (3) the Joetns
had died early, and the placenta bad gone on growing.
Mirroscapical report. — Microscopic sections from the
wall of the tubail pregnancy had been made. Between
the wall of the tube and the amnion, the ifpace was chiefly
filled with extravasated blood, in some parts quite recent,
in others begiuniii^ to be organised. Recent blood wan
met with in all ptirts, close to the amnion as well as near
tbo wail of the tube. Aniidat the oitravasatod blood
chorionic villi could bo seen, many of them filled with
blood. The wall of the tube was infiltrated with round
cells, but not thickly, except in a few places. The ams-
ouIeu* bundles were more separated than normal, and tba
fibres were slightly larger than usual. There were spaces
that looked like the lumen of glands, but had no epithelial
lining-. Ku large decidnal colU could Lo seen anywhere.
PELVIC ORGANS OF A PATIENT DYING FROM
INJECTION OF ACID NITRATE OF MERCURY
INTO THE VAGINA TO PRODUCE ABOR-
TION.*
By JonN PniLLirs, M.D.
Db. Puiilifb called attention to the site of the infec-
tion in. the Tafjinn, the untouched tea weeks' ornm, the
congested conditioQ of tho right broad ligament and the
general -sloughing of the rectdl amcous membrane. He
deferred many intereEting points in the case to n fartlior
contribution on the subject.
?or ioquciit. sve 'Time*,' June 4th, 18M| fur trial, Hid.
CASE OF SYMMETRICAL ERYSIPELAS, FOL-
LOWED BY PREMATURE LABOUR; ECLAMP-
SIA ON THE NINETEENTH DAY POST
PARTUM ; TWENTY-EIGHT PAROXYSMS j
NO RENAL DISEASE; RECOVERY.
By JAMIE80JI B. HoEET, M.A., M.D.
(Heceiretl Febmarj- IStb, 1B90.)
E. W — , tot, 35, W-para ; pregnant niao uud a half lunar
months.
September 7th, 1880, noon. — Seen for the first time
this morning. Her previous hiBtory shows freedom from
nenrotio disease, and during the present pregnancy her
health has been good until this momiog, wheD (without
digcorerahle cause) the following symptoms have appeared :
severe licadache, pains in limbs and loins, shiyering, rapid
pulse, hot fihin, anorexia. At 10.90 p.m. she was suddenly
delivered of child before arrival of doctor. Placenta ex-
pressed a la CtpaU, withont a single vaginal eiamiQation.
8th, 2.30 a.m. — Post-partum tfeinorrha^e of moderate
Bovi-rity, arrested by vigorous kuoading of uterus and
large doses of ergot. A siaglo exploration andortakon in
order to remove clots from uterus, il a.m. She looks ill,
with same symptomB as on September 7th.
0th. — In front of each ear, and extending perfectly sym-
metrically on both «ides over an area equal to that of &
florin, is an erysipelatous eruption. The skin over tlie
affected area is hot, tender, swollen and pits on pressure,
suggesting at first the possibility of deep-seated suppura-
tioQ. No resemblance in ether respects to Rcarlatiaa.
NoBore throat. Temperature lOi'5® F.; pulse 125. Lochia
natural, not offensive.
lOth.— PaticDt seen by Mr. George May, F.R.C.S., in
consultation. She pi-oscnts all the local and constitetional
[Symptoms of erysipelas. Tho eruption aSects both sides
810
BTHMETBIOAI BBTSIFSLAS.
of the Ence sjmmotrlcAlly, and covers larger areas thaa
yesterday, nlthough these areas do not meet in the median
line. Strict antiseptic precautions orderod, namely, boracic
acid padft (instead of diapers), to be changed as rapidly
as possible ; carboHsed steam to be diffused throagh
room ; semi-recumbent pnature to be assumed for a few
minutes twice a day. Vaginal imgations forbidden ; ven-
tilation of room attended to.
lltb. — Erysipelatoas eruption has spread from the two
areas first attacked and now covers most of the faoe.
The coastitnt-ional symptoms are very severe. Pulse 132 ;
temperature lOi F. a.m., IU3* p.m. Lochia continue
inoffenaive. Uriue free from nlbumen. Suckling discon-
tinued, on account partly of the risk of infection, partly
of the deficient supply.
12th. — Erysipelas covers the same extent as yesterday.
Patient is taking food fairly well. TempeTflture lOS'l" F.
a.m., lOi'-i*^ p.m, Slight tympanites noticed to-day for
first time.
13th, — Erysipelas is slowly receding. Lochia natural.
Abdomen is tender and tympanitic. Temperatnre 102"
a.m., 104'6 p m.
17th. — Gradual improvement during last four days.
Temperature is slowly falling. The abdominal tenderness
has been conaiderablCj affecting mainly the right inguinal
and hypogastric regions. There have been no rigors nor
any indication of septic mischief, except the abdominal
tendepuesfi and tympanites referred to above. Ijoohia
natural; urine normal, free from albumen.
2l8t. — The tenderness in hypogaatrium is much less
marked. Patient looks better. Pulse 9S; temperatnpo
99" a.m. and p.m.
Daring the oext four days patient appeared to be doing
well in all respects. Her temperature had been normal ;
pulse about 80 ; tongue clean. The abdominal tendcruoita
had almost gone. Lochia perfectly natural. Appetite
good. There was nothing to indicate the approaching
complication.
STMMETBICAL ICRT8IPELA8.
26th, n a.m. — Patleut complains of Bevera frontal
he&daclie, bat otberwise appears to be doing well. The
peeling of the face dae to the erj-sipelaa has almost ceased ;
but there is a serous discharge from, and deafness of, tha
left ear. At 9 p.in. she wn.s suddenly censed with epilep-
tiform coDTulsions inyolviug the whole body. There was
total lou of conecionsnosB ; pupils dilated, giving no
reaction to^lig^ht; conjunctival redox abotiabed ; slight
foaming at mouth; urine passed involuntarily, £j 10
p.m. conscionancss had partially returned.
27tli, 0,30 a.m. — There have been six more fits this
srning, tbreo being very severe, the last occurring while
May and I were seeing her in consultation together,
the characters of eclaRiptic convulsions mentioDed
above were preaeut. Chloral, gr. L, was given per
reetum, and chloroform inhalntions ased. 8 p.m. Bight
more fits occiirrod to-day in the course of one and a quarter
hours, bat less severe than those of the morning. During
the afteraoon patient has lain in a semi-conscioDS condi-
tion. Temperature normal.
28th, a.ra. — Three more fits occurred doting the night.
Urine passed voluntarily for the first time aioco tho onset
of the (its ; it contains no albumen. A careful searcli wag
mode for any cause of the convnUive attacks, but without
encoess. No local tenderness or pain, except headache.
8 p.m. Eiglit more fits have occurred since the morning,
but of much lean severity. In some of them only tho facial
musclea were involved, and conxciousneBE was only partly
loet. Temperature 99-6'' P. a.m., lOO' p.m.; pulse 100.
The nrine was tested whenever passed, but never con*
taincd any trace of albumen.
October 2nd. — During the last four days there has been
a complete cessation of tho attacks. Patient takes nourish-
ment fairly well, bnt i^tiU complaina of hfadacbe. Mental
powers unimpaired. The discharge from the ear has
ceased, and good hearing is regained.
]3tb.— Patient is well.
SIS
I
STHHliTBICAli SBTSIPBI
Bemarhg.
Ttis case, of wliich the important. fcaturcB liave juat
buen QArrtited, is of peculiar interest from ecToral points of
view.
Firstly. Erysipelns attacking a woman immediately
before labour, and apparently inducing premature delivery,
is in itself a very unuaual event.
Secondly. So far a,& I am aware, no ciwe in which
erysipelas has attacked opposite aides of the hody simQl>
taneously and symmetrically is on record. At any ratOj
BO rare is this occurrence that at the famous discussion on
" Puerperal Fever *' at the Ohstotrical Society in 1.875,
Mr. Jonathan Hutchinson, F.H.&. (speaking of the speci-
ficity of erysipelas} declared;* "We never see it (i.e.
erysipelas) prevail symmetrically in the two halves of the
body, as it certninly would do, if it ware due to the intwj-
duction of any specific germs, which would develop io the
Baiue manner as we know the Epecific poisons of smallpox,
scarlet fever and measles do."
In thus aflBruiing that erysipelas may, from the com*
mencemeiit of the cutaneous eruption, involve two sytn*
metrical portions of the body (and I would point out that
thiepatient was throughout under the closest observation),
I am glad to have the confirmatory testimony of ao expe-
rienced and caatioQs an observer ae Mr. May.
Thirdly. The possibility of erysipelas of the faco
attacking a lying-in woman without provoking puerperal
septicatmia of any severity is also interesting. If, as
appears to be established both by cliuicat observation and
bacteriological experiment, f the same virus may provoke
erysipelari and puerperal fever, we should perhaps have
expected that a lying-in woman suffering from erysipelas
of the face would run the greatest iiak of puei-peral aepaia,
and yet in the case before ub uo symptom of such scpsia
• Cf. 'Obrtct. Tnini...' vol. svii. p. 118.
t Cf. inttr alia Dojen't cipcrluicuM, iiuiiitDarin«l in ' Brit. MmL Joan.,*
18tl«,),I>. 031.
4
4
8YVUETEI0&L BRT6IFBL1S.
Rppcnred, unless wo assigu tbo tympanites Bud tendoruess
to sccli cause. Witlt thia limitatiou, her symptoms oorre-
Bponilud to tboso of au attack of fanal eryaipolas.
In seeking^ for a. po5stb1e explanation foi* the imuiunity
from general sepsis, I am mnch tempted to adopt, as nt
least a useful working hypothesis, a sDggestiou made by
Dr. Playfsir* in regard to tlie relation of zymotic diseases
to puerperal (ever.
It is wotl known Low various ia tho experience of
accouchoura in regard to exaotheiuata during tlie post*
partam state. On the one hand, we find Spiegclbttrgf
declaring that " the puerperal virus has no particular con-
nection with the poison of tho acnt« exanthemata ;" and
again " that the acpte exanthemata may broak oat in
lying-in women, and even in those attacked by septic
diBeasex ; but when they do so, the zymotic; disea-ses and
the piierporinm or the puerperal eopsis, in the main,
advance quietly side by side, although no doobt their
characters may be more or lesa modified."
On the other baud. Dr. Braxton Hicks] holds that a
puerperal woman, tvbcn affected with scarlet fever, devotups
puerperal fever; and another obstetrician, Dr. Tyler Smith,
declared from the ch&ir of the Obstetrical Society^ that
" any of the agents which produced zymotic maladies might
cause puorporal fever."
A different view, Agaiu, is hold by Dr. West,!! namely,
that the acute exanthemata sometimes breed trae in the
lying'in woman — that is, variola produces variola ; at other
times tbey give rise to disease indistinguishable from
puerperal fever.
Dr. Playfair, in discussing these cases, writes: "It
seems to mo not improbable that the explanation oE the
lad that zymotic poiuon may in one paerperal patient
• -Science iini] I^motioe o( Miilwifer;,' 1980, 11. p. 340.
f New Sjdonluua 9otaHj'» tmAtlatioii, il, p. iSt*.
t 'OUlclrioal TtuiMctiou,' vol. w, p. -H.
S lUd., tol. ill. p. 40S.
lUd., TOl. ivU, p. 287.
S14
STHUSTRICAL RRTSr PBf.AS.
run ite ordinary coarse, and in another produce symptoms
of intoneo septioocmia, may be found in the cbaunol of
absoi*ption. It is at any rate comprehonsiblo that if tho
contagion bo absorbed through tlio skin or ordinary
cbannel, it may produce its cba.racteriatic aytnpiotns and
run its nsual course ; while, if brought into contact witlt
lesions of continuity in the generative tract, it may act
more in the way of septic poison, or with such intensity
that its specific characters are not developed."
"Without for a moment wishing to minimise the great
diflSoulties that lie in the way of onr accepting tliia view
(and a discussion of them would involye such moot qnea-
tionfi as the local or con&titutiona] nature of orysipelas,
and the moaning of "specificity" as applied to zymotio
disease), yet I may point ont that the treatment of the
above case was based upon it, and apparently with snocees.
By preventing the access of contagion to the generative
organs by antiseptic pads rapidly changed, and by dis-
infecting the air of the room, efforts were made to keep
the generative tract, so readily inoculated in the poHt>
partum state, free from the virus of erysipelas.
Fourthly. It is very unusaal for an iiiter7al of nine-
teen days to elapse between delivery and the outbreak of
eclamptic convulsions.
Fifthly. Recovery after so large a number o£ eolamptio
ftttftoks as twenty -six is rare, bat by no means unrecorded.
Sixthly. The total absence of albuminuria or other
renal symptoms is also noteworthy. The nrin© passed in
the interval between two rapidly successive paroxysms
was more than once tested, and always with a like
result.
Dr. Bu&XTON Hicks wished to point th&t the author had fallea
into a mistnlte wliicli mauy otbera hud made, both here and in
America, namely, that in the paper he had brought before the
Society many yeare ago, ahowing the clinical aurromnlmKB of a
nutnbor ufcaaeB ol' puerperal dmene^E, he bad stated that puer-
peral fever was caused by ecarlatina. If this paper were carefully
read, together with his remnrke in the diBcuuion of puerperal
SmRTGTC&L ZETSIPBUS.
fever in rela,tion to iufective diseases and pyaemia, it would he
wen tliat hv had not made that assertion. He had endeavoured
to do what but fi>w, eucli as Dr. Boxall and the author o£ this
paper, bad done, u&nicly, to being facts befwrB the Society. lit had
endeavoured lo correct this niisapprelieiisiun uf what he had Maid
hy publi«hiii? nn explanntion iu the ' AiiJ«ri(.'aQ Journal of
Obstetrics,' Ma^, 1&88. That there ia an intimate counection
botweou zymotics, erysipelas, &c., and puerporBt fever, so called,
tlher« could be no doubt, but the eiucrt nature of the relationship
;et had to be made out. For himeelf, it 6oemed. most likely,
according; to our preaent knowledge, that in the bad coses,
eimilur to thotte seen iu hojtpitale farmerly, there trere two
poiKona acting concurrently, and this probability was pointed at
Dy our president in hia addresn. However, Dr. Hlihscuocltided
by saying that the solution of ibe quettion could only be found
by continually colloctiufr cUoiual hieturica from all part« of the
world, particularly in nevr towaa not yat saturatod with zymotic
diaeaaea.
Dr. Hrbuait said that Dr. Hurry took it bb estnblished that
«ryiipelas was one of the causes of puerperal fever. Thla riew
WM based upon the experience of certain lying-in hospitais in
Dublin, Paris, and London, in which the preFtence of a case in the
hoitpital or itsneishbourhood Lad preceded the outbreak of puor-
poral fever. In King's College HoopiLal. the presence of cry.
eipelas in the surgira! wards had been found to go along with fever
in the lying-in vrard. But lie (Dr. HormeD) did not think this
by itself showed more than that the tvru diaeofies flourisbed and
spread under ideutical conditioua. The opinion bnd also been
supported by Dr. Minor's book, in which he compared the pre-
Yalence of eryoipeias and puerperal fever in difl'ereut >»tate8 of
America, and proved to hta ova satisfaction that the two diee&aea
prevailed together. But b« (Dr. Herman) did not think that
the evidence adduced by Dr. Minor bora out his conclusion.
The 80>ca11ed "epiclemica" of puerperal fever were only very
alight elevations of the number of cnseei above the general
BTCTSge, and the uumbor of times that on iucreaeed death-rate
from erysipelaa went with an increased deatb-rutc from puerperal
fever was not more than could he accounted for by lortuttous
coincidence, together with the fact that the spread of both
diseases was favoured by uneleanliue»a and bad ventilation.
Thus both dineuses were found eBpeeiftlly frequent among
Gercnan immigrants. The (Question had been obscured by the
inclusion of two diifereDt diseases under the term erysipelas.
Cutaneous eryeipias, Hhich Fcbleiseu bad Hhuwo lo depend
upon a specific coccus, which could be cultivated and inoculated,
reproducing the disease, was quite a diflerent thing from phleg-
monous erysipelac. Phlegmonous erjaipoUa he (Dr. Herman)
bad no doubt waa one of the diaeasee included under the term
816
STlDIKTBICii KBTBIPBLifl.
poerpenl ferer. The poison of thia dieeitefi produced as tcrribte
eonSMuenct's wheo inoculated into a rent in the pcrinrcum as ib
did vnen it got Juto n wound in a limb. Thin nan the diaeaasi
whicU Virchow hod called en/slpetat maltjnum internum. Baft
cutaneous erysipelas, when communicated to a )}-iug-ta womAO,
produced ouly the siLine dieease as it did in any other patient.
tiuBserow had published a series of cases which showed this.
He CDf. HermsQ) had seen cutaniiouB eryeipeliis in the lyiug-ia
woDi&n, and also io the infant, nnd it ran juat the «ame coursa
88 in a patient who had not been delivered, s.nd did not produoa .
puerperal fever. He agreed with Dr. Braitoa Hick» that caaei^
m which [latieotB appeared to Buffer from erysipeias and front
septicaemia were cases of mised infectious, lu nliich the poisoa
of both diaeaaea had been received by the patient.
Dr. Heiwooi) 8MiTti wislied to koow if an; obserratioDa had
been tnlsen of the frequency or character of the pulse between
the fits.
Dr. BoxAiL said that the subject so ably pTeaented to the
Society by Dr. Huri-y was to tiiiu of peculiar personal interest.
Indeed, it will be found to occupy a protaiueDt place ia tlie
next part of bia paper on " I'ever in Cbildbed." On that account
he would uot at present detail the evidence which he hoped at
no diBlaat date to lay before the Society. At the same time, he
visLed to take the present upportuuity of niakiog a few remarkt
of a general characler on Bome points in the paper. And, at the
outset, he would draw a diatiuctiou betw^eea facial, and — a« it
might be termed — pelvic, erysipelas. For, though couvinced
tfant both were due to tlie aanie cause, he uevertlieless recognised
that the difference in the primary site of the local mflaminatioil
entailed great divergence ia the di nical aspect and gravity of such
cases. Facial erysipelas, such iis the author had described,
judging from the literature of the eubject, was aa common bofora
ae after labour ; even more so. But after delivery pelvic err- '
■ipelas held the first place. In speaking of the latter he would
have occasion to draw attention to Winckel's work, ' Cber da*
fuerperaleEryeipel," which formed loost inatnictive reading and
rought this point into prominence. For the present, however,
he wiahed to limit his remarks almost conclusively to eryaipela* ,
primarily iiUackiug the face. That such a febrile illneae aa ery*
eipelaa — facial eryaipelaa— was competent to induce premature
la hour was well known, and many such occurrences were on record.
Dr. Boxall would ask the author if, for purposes of future refer-
ence, he could give tiie duration of the pregnancy la days, dating
from the end of the last menstrual period. From a study of the
literature of the subject (which, however, he had Dot yet ex-
hauated) Dr. Boxall was disposed to agree that the bihiteral and
■imultaoeouHappearanceoftae erysipelatous process was probably
unique, though to him it aeemed a poBsibility which might at any
SYUMETBtCAL ERTSIFELAB.
317
timo occur. By way of analogy he might instance tbe rare occur-
reiiL-e of wbitlow on both bunds pimultaQeousty. To hie mind
whitlow and fncial eryeipcLns preepnted so many pointe in comtnotl,
that contemplation of the behavtour of the former might serve to
render plain the after-course of the latter. To begin witb, the
chance of finding a local breach of surface was about on a par in
botb casee. Iti both, the Qtrt;i.-tion, tbcui;b attended with a certain
amount of couBlitutiocal iii§turbance, waa primarily local, but it
might ultimately become general, or lead to the establisbment of
otlier inflamiQatory foci, sucK aa aometimea occurred in tbe {>elvi8.
Further, this local pelvic iuflauimRtiou might ensue in one of two
ways. Id the case of whitlow, septic poiaon, and in that of
facial eryeipelaa, erysipelatous poieon, might, on tbe one band,
Bprend from its original liabitat through tbe tissues of tbe body
and, lighting upon already damaged pelvic tiNSUoe, produce an
acute loriu of inflammation ; or, on tbe other band, from tbe fame
local foci, either poison might be given off, and, after escaping
entirely froin tbe body, re-enter it through the genital tract,
bocotnoahRorbcd, and $et np in9nmm,ition in the pelvi#. To tbe
remarks of tho author under the third beading, Dr. Boxall
wished to direct particular attention. In the first place, he (Dr.
Bosall) was willini* to regard the coee in point as being tn all
probability one of facial erysipelaB per ae. For it was his
opinion that bad the pelvic organs become iovolred ia the
eryaipelatou* proceiw, and bad pelvic erysipelas pesulted, the
physical siKDS (such na the tympanitcit and tenderneas) would
probably have been more pronounced, and the case would
flltogother haveaaanmed a graver aspect. In the second place —
and in this he must necessarily trench somewhat on the evidence
to be brought forward in tbe second part of his paper — he was
convinced that the erjsipelatiins poiaon itself, whan it implicated
the I'ehic orgunn, pruJucL-d a local and general diaturbuDcc,
which, as far as clinical ob-^ervalion was concerned, was wry often
indistinguishable from puerperal fever as generally understood,
and invanably resulted in a puerperal disease of grave and often
fatal type. It appeared well estublisbed that no blush appeared
beyond the vulva in many such caics, and consequently theip
erysipelatous character was apt to pasa obaorvation. On the
other band, lie might add that ne waa far from believing that all
puerperal fever, or gvod nil pucrpernlfevt-r of the graver kind, waa
6ryeip«IatouB,bficauaeothcr poisons, which wereeeptic butnotery-
sipelatotis, were capable of producing a similar — lie might almost
•ay identical' — clinit^al rextilt. Now, granting that erysipelatous
ptUMD tnigbt itself produce a form of tiuerperal fevec (in Tcality
■n fttteck of erysipelas tDdiBtingutshotle in diniciil aspect from
septicemia with pelvic inflammation), we certainly should have
expected, u Dr, Hurry said, that a lying-in woman sufiering
from eryeipelas of the lace would run the greatest risks of puer-
818
STMUETBICA^L BRT8IPELAS.
perol sepBis. ^fany sach cases, howerer, ver« reported in vliich
tbe erysipelatouB poison fniled to reach tlie pelvis either by
extending through the bady-tisaue« or by direct reintroductioa
through the genital paeeages, eepeciallf where such meaaures as
tho«e referred, in the paper were adapted. Finally, with rcg&n]
to the working hypotheeis mentioned by the author. Dr. Boxall*
while agreeing th&t it held go^d in the ewe oE erysipelas
trusted that we should soon henr the last oF it as applied to th0
aymotio diaeaaes generally. For he reutured to say that, if, aa
bad been done by hiiuei^lf in the c^iee ot acarlatiuu, a eeparato
seriea of cMeti of eiich of the zymotic diseases had been collected
ID which the eoiiree of infection could be arrived ut with sotne
approach to certainty, it would be found that many of tbe rerv
worst Cftses, and caaes of a marked character were those id which
direet iooculation could be comptetely eliiaiuated. This was chieSy
due to tbe fact that in many auch ca^es tbe pntient had obvioiuly
received infection prior to the onset of labour, and then iu all
probability through the ordinary channels. And seeing that there
BtiU reuituned similar anomalies which could not be explained,
even when these difeoseeoccurrod apart from puerpery, anomaliea
to which ohvioualy no theory of direct inoculation through th«
genital tract could poBBibly be applied, Dr. Boxall would prefer
to await patiently a rational explanation, to seeking solace in
so groundless a tlieory. Tbe confusion which had iu no small
measure ariaen through arguing from one dieeaee to the other
— through concluding that because erysipeUa did tlii»,Bi-arIatina
must doTitewIae and measles follow in the same train — would only
be obviated by keeping fhe bebnviour of each disease separately
before the mind. And, at leaet as regarded erysipelas and suurla-
tina, be was convinced that a very wide difference existed in their
tendency to implicate tbe pelvic organs when the dieeoae attacked
a recently delivered woman.
Dr. Amasd RoiTTn thought that as there was distinct ©ti-
denee of otitis, the convulsions were due to a transient meDio^
f;itie, eeccndary to the erysipelas, and were Qot, in aoy etiological
sense, puerperal.
Dr. Cletelami) disagreed as to tie analogy between culanoous
facial erysipelas and whitlow. From what he had seen of both
BfTectioDB, there was do tendeucy to suppuration in the former,
while in the latter it was marked. He h.xd always regarded the
importation of pus into puurpend surroundings as an element of
danger, and could understand the Deces&ity for taking pre-
cautions if a lying-in woman happened to be suffering from
whitlow,
Br. Hc&BT, in reply, thanlted the Society for the kindly
reception accorded to his paper, which was a small contribution
towarda the settlement of some difficult problems in obstetrica.
To Dr. Braxton Hiuka au apology was due that Jbia TJewa bodC
820
FOUR CAiSES OF PREGNANCY WITH BRIGHT'S
DISEASE.
By G. Ernkst Herman, M.B.Lond., F.II.C.P.,
ODSTSTSIC PHrtlCIAN TO TUX tOITDOK UdlPITJU.
Beccivctl JoDuary 11th, 1990.)
{Ahstrael.)
The a.uthor points out that to under3ta.Qd the relation betwc^a
renal diseaBf iu [ireguftnt woiiif u ami cclauipaia of pregnancy, it
is Deceesar; to roinpare ccises of renal clia^rtso with wlaiapsta
with ciLses of renal disease without eclampain. Four caiiftx of Hie
Ifltter kind are defailed iu tliis paper, of which the chi«f fcaturei
are as follows :
Case 1, — Second prognancy- Morning Biokneaa ceasing n1>out
middle of third month: Tomiting rftuming in seventh montii,
together with cedema, giddineas, amblyopia, ind disturbed ttleep :
slight iLDsetuia ; att marked oardiiLc hypertrophy : urine solid
with albumen: quantity of uriae iQcreased : excretion of urea
Blightly hfllow the «venigL»; induction of labour ncAr cod of
seventh month : child living : rapid diuLination of albuminuria
fLud tucrease of urea-excretion following delivery : recoverv!
subsequent preijiiaucy without similar renal changes.
Casb 2. — Sixth j)regii.ancy. Twine: hydratumoe: a-dema in
last fournionths of pregnancy : no other symptoms : nrino solid
with albumon, about half paraglobulin : slightly dimiui8hi>d
quantity of urine and urea: labour acct'lemted by separution of
membianea around o» uteri: children living: delivery imm^
dJotely followed by great dimiaution in albuminuria, greaftj
diui-eais, and augmented urea-elimination: temporary return of '
albuminuria during latter part of lyiug-iu period : apparently
complete recovery.
Cas& 3, — 8u[teoath pregnancy. Fits after coufinemeat six
PRBQNANCY WITK BRIGHT S DISKA^SE.
321
Vflara previoiislj" : syraptoma comiug nu at beginniTiE; of ciglitli
uoulk of proacut pregnancy: iotra-uieriae death o£ fcBtiia:
premature labour induced at end of eighth month, after one week's
trmtmetit by rest and milk diet : no diminutioD in quantity of
iirine.but diniiniHlieduiea-eliaiiuation : albumtiiurla: diminution
of alltuniiuurta and partial reaturatian of uroii-excretian before
delivery, fioutinuiiag after deliverj: recovery, bat persiateuco
of renal diseaae.
Cahx 4. — Albuminuria: unemic twitcbings : cerabral bsmor*
rbagc : induction of labour at bi-^nuiag of eighth montb: cbild
liriog: dimiuisked percentage of urea bcfuru dclirory: after
delivery rapid increaee in percentage of urea, and temi-orary
diminution of albuminuria : renewed cerebml heomorrbage:
coma : death : no antopi;.
The iiutbor <^omnient8 on Ibo special features of each case:
the dimiuisUed albuminuria and increased urea-escretioa wbicli
followed dolivory in uU ; these cffeeta of deHvei7 being greatest
in Case 2. in wbieb the abdominal distention was greateat, and
least in Case 3. in wbicb the ahdoniinal enlargement was least;
Cue i being also contraetod with others as to the amount of
ftlbiunea,aud the duration and persistence of the disease.
1 have in former communieationa put before the Society
ca«e« of eclampeiu in wbicb the condition of tbd renal
fanction was noted with especial care. But in order to
ooderstand what part aUeralioDs in renal function play in
the production of eclampsiu, wc must compare tiuch cases
wibh others in which there is renal disease wtthoat
eclampsia. In tli)9 p&per I sabmit booiq cases of this kind.
Case 1. Second pregnaney ; morning sithxeaa ceavmg
about middle of third month ; vomiting returning in seventh
monlh, together toith ^dema, giddinea*, amblyopia, and
disivrbed aUeji ; slight anfemia ; no marked rardiae hyper-
trophy ; urine gnlid with albumm ; quantity of urine
inerea»ed : excretion of urea iilighlly below the average;
induction of labour near end of seventh moiith ; child
living ; rapid diminution of albuminuria and increase of
TOI.. UXlt.
23
PBC0H&NC7 WTTB BRISST 8 HISEASS.
urea-*9.eretion following delivery ; recovery ; subsequent
pregnancy withonl »imilar renal changes (from notos
by G. A. Pratt, House Physician).
F. P— , single, pregnant with second ohi]d_, admitted
into tha Geneml Lying-in Hospital, April 5tb, 1888.
Previous htstorj/. — No scarlet fever or any other illness.
First child bom PeWuary 2ud, 1885; pregnancy normal.
Can gire no account of confinement, as slie was delirered
under anseethetic. Child liad spina bi6da and club feet.
Began to menstruate at thirteen, but catainenia did not
reappear for some months, after which Hieywere regnlari
moderate in quantity, lasting three days. No pain. Lust
menstmated during second week iu August, 1887, qaantity
as usual. Thinks she became pregnant the day after
cessation of Sow. About a fortnight after last menstrua-
tion, nausea and retching came on immediately on rising
in the morning, which continued till she romitod. This
ceased after lasting two months, bat returned in Marcli,
1868, about three week» before admission, Toinitiug
occurring on fire or six tnomings, and ou two occasions
daring the night. Since Christmas, patient has had to get
out of bed three or four times during the night to pass
water, passing ouly small quantities, with some pain,
at each act. Her legs have been swelling, especially at
night, for two months, bat only slightly until the first week
in March, 1888, when patient had to leave her work one
day, owing to the swelling of her legs and giddineea.
The vulva aiso swelled, and her face has been swollen
during last week. There has been ocoasional dimness of
sight during the last week. Patient has had a yellow
vaginal discharge during the whole of pregnancy, but
during the last two mouths it Las been &o free that a
diaper had to be ased continually. No headache, but a
sharp, almost coutinuoua, pain in each tetnporal region.
For some weeks past has not slept well.
On admignon (April 5th). — Patient was pale and pasty
looking. No marked ansemia. There was cedema of
both lower extremities, extending as high as the gn)in«
PBEOSAKCt WITH BBIQHT'B DISSASB.
323
on either side. No oedema of abdominal walla. Greatest
abdominBl girth 30^ inches. FqdcIub uteri 2^ inches abo7e
nmbilicus. There was marked uterine obliquity to the
right, which altered with the position of patient, being
towards the left when pationt had been lying on her left
side. Fcetnl benrt audible. Ci\rdiacdu]no3S not increased.
Apex-beat to inner side of left nipple. Eedaplioation of
first sound at apex, aecond sound loud and sharp at base.
No abnorinal eigua in lungs.
Oo vaginal examination the portio vaginalis was found
to be I in. long. The os externum admitted the tip of the
finger, bot os intemum was closed. Vertex presenting,
freely moveable. Promontory of sacrum not felt. Ex-
ternal conju^^ato 7 in.
OphthaliQological examination showed no morbid
changes. Patient to be kept in bed, on milk diet, and
allowed plenty of distilled water to drink. Pulv. Jalapre
Co., gr. XXX given. Uriue to be drawn o£[ by catheter
beforo each stool.
April 7th. — There being no change in condition of
patient, the uBUal autiseptic precautions having been
taken, a No. 10 gnm^elastic bougie was introduced between
the uterus and foetfl.1 membranes at 10.30 p.m. At 11.15
p.m. a small quantity of liquor amnii began to escape.
8th, 6 p.m. — Paiaa regular every ten minutea. Pre-
sentation second cranial.
9th, 2.15 a.m.— Os fuUy dilated. 2.30 a.m. Child born.
Very little hsmorrhago, in all about 3 oz.
Child, male, 17 inches long, weighed 3 lb. 3 oz. Pla-
ceEta weighed 13 oz.
The lying-in period was satisfactory. The oedema
passed off rapidly after delivery. On the third day it was
very slight.
During first weok patient frequently complained of pain
in temporal regioD.<j, and also in region of sternum.
On the eighth day puitivnt hat:! 6sh diet, and on the
ninth moat. She was now allowed to sit up.
Fationt had a fair quantity of milk, which was drawn
PBIOHAHOr -WITH BBtOHT'e DISBASB.
325
off by breafit-pnmp and cIiiH fed with it, it beiog too
weak to suck. The child waa placed in the incubator,
&nd took its food well.
Temperature. — Up to the time of delivery the tempera-
ture was nonnnl or sabnormal. Three hours after delivery
it roachod 100°, but soon fell agaio to normal ; on the
Bvening' of tho second day it re&ched 101*2°, which was
"probably caused by some slight breast Ironble, as it soon
fell to noriUBl. During the whole of patient's stay in the
Iiospitat the temperature was taken every fonr hours, bnt
it remained normal until her discharge.
Urine. — During the whole of patient's stay in the hos-
pital the ariQe was messored every twelve hours and
examiced.
At first nil urine was drawn off by catheter, but this
was diecoatiouod. two days after delivery. After this the
nrino was passed by the patient and saved by the nurse j
bat the catheter was used immediately before the bowels
^were going to act, so that very little urine was lost.
Quaiitilj^. — Up to the time of delivery the average
quantity of urine passed per diem was 61 oz., bub the
daily variations were great. Before delivery, the largest
|D&stity pasNed in twenty-fonr hours was 8i oz. and the
'■minimnm was in the twenty-four hours jnat before do-
livery, when only 44 os. were passed. In the twenty -lour
hoars following delivery the quantity rose to 72 oz.
On the second day after delivery, the qoantity was 67 on.
in twonty-fonr honrti, bat on the foarth day it fell to 26 ok.
Oq the sixteenth day after delivery the patient passed a
large quantity of limpid uHdo, 113 os. in twenty-four
hours, this being probably due to emotional causes ; and
on the neventronth day 65 ox.
Sjieci^c gravity. — On admission it was 1008 ; the day
before delivery it rose to 1015, and immediately after
delivery it rose to 1020, which was the highest reached.
,. After this it varied from 1008 to 1018 ; but on the seven-
teenth day, when the large quantity of arino was passed,
tbe &p. gr. fell to 1004.
S2«
FREaNAHCY WITH BBIOBT'S D1BEA8E.
Albumen. — On admission the first urino examiood
turned solid on boiling. Next day it waa one>fifth, and
the day before delivery a half. After delirery the
quantity of albumen at once fell to one quarter, and
coDtinued steadily dimiDisliiDg, bo that on the sixth day
after delivery there was only a trace. A very faint cload
-was atill seen viheu patient wae diecliarged. The albumen
did not increase when the patient began, to take ordinary
diet, nor when she got np.
Casta, — Urine contained a few hyaline and granular
casta, but they were never numerous. They were slightly
more numeroua immediately aft«r delivery than before.
Urea. — The urea was Gstimated twice daily during the
whole Gtay in the hospital by Squibb's apparatna. On
admisEion, the urine only contained 0' 7 per cent, and re-
mained so daring the £rst day, the patient passing 244
grains of nrea in twenty-four hours. In the twenty-four
hours preceding delivery she passed ]90 grains of urea.
Immediately after delivery the quantity rose to 262 grains
in twenty-four houra ; on the eighth day to 606 grains.
After thiB it varied between 420 and 550 grains in the
twenty*foar hoara. On the day in which the largo qnan-
tity of urine was passed the percentage of uren. for twenty-
four hours fell to 'Si, but rose again the following day.
On April 26th, 1S88, the patient was sent to the con-
valescent home.
Her urine was examined on May 2dth, 1888, and still con-
tained a faint cloud of albumen, and 1*22 per cent, of urea ;
she passes about three pints in the twenty- four hours.
December 16th, 1889,— Confined NovembBr24th^ 1889—
she thinlcs at about three weeks before her time. Last
menstraation ceased Dec. lOth, 1888.
During pregnancy frequently came over with a " Hilly-
feeling," not headache, but a peculiar feeling in the head.
Much more vomiting than in the former pregnancies.
Went to St. Olavc'B (Southwark) Workhouse about Novem-
ber 8th. Urine was tested by Dr. P, P. Wightwick soon
after admiesion, and a trace of albumen found. Labour
PBKOITANOT WitHBRrOHT 0 I1WKA8E.
327
lasted ubout six hours. The liquor amnii was discharged
twenty-Eonr honrs before pains began. No anasarca nor
ascites while io tho workhouse. Urine alwaye contaiacd
a trace of albotnoa. No convukioDs.
Pationt is thin : not markedly anssmic. No (sdema.
Heart's apex-beat below nipple. No marmtir. Feek
urell except that Bhe thinks ebe is weak. Urine sp. gr.
1020, scid, trace of albumen; a few granular cants.
Labour was induced in this case for the sake both of
the mother and the child. For the sake of the mother,
becaase to allow the pregnancy to go on would have been
to expose ber to increu^^ed risk of (.•clampsia, and increased
probability of renal disease persisting after delivery : while
experience has abundantly shown that in renal disease
coexisting with pregnancy rapid improvement ueually
follows deliTcry. For the sake of the child, becaase much
evidence has been brought forward by Fehling^* Wiedow,t
Cohnjt and others, to show that in Brigbt's disease with
pregnancy, intra-aterine death of the foetaa is frequent :
and cascR which I have published show the samo thing.
In this case the excretion of nrea before delivery was
a little more than half the average of health. This was
probably largely an effect of restricted diet, for the daily
quantity waa only slightly increased by delivery, but rose
to tho full average of bealth when the patient was put on
moat diet.
Some diminution in the albuminuria followed rest and
milk diet, but the quantity was increased again before
delivery. After delivery, as ih almoRt invariably the case,
there was a rapid diminution in the amount of albnmen.
Although a trace of albumen in the arino remained, a
further pregnancy was not attended with a recurrence of
similar kidney change.
Cask 3. Sixth pregnancy ! ttetntt; hydTamnio* ; adema
in iaat four months of pregnancy ; iio other gymiitoma ;
• ' Aroh. fflr Oyn.,' Banil xxvn.
t ' Z«iU. fttr 0«b. UDd O7B.,' Band xlv.
ftas
PBEONAKCr WITH BKiaBT's DISBASS.
urine noUd joitk albumen, about half paragtobuUn • alighthf^
diminished qitantity of urine and urea; lahuur aaselerataA
bjf separation of meinhranes round o» ; ckildr«H living ;
delivery iriirnediately followed ly great diminutian in aSntmi
minuria, great diureeis, and augmented urta-elimiiiation j
tomporary return, cf albuminuria dwrtJtj latter pari of
tying-i?i period ; apparently complets recovery. — B, A — ,
aged 36, admitted into the London Hospital uuder the
care of Dr. F. Charlewood Turner, May 17tli, 1888. {I
have to thank Dr. Tnrnot' for calling my attention to this
case, and for permitting me to pnblieh it j and Mr. G. C.
Wright, Resident Accoucheur, for the notes and for the
meaearoment and oxamination o£ tho urine.)
Patient Bs.id she had been married ten years, and bad
had five children, all living, and one miscarriage. She
worked aa a tailoress. Haa had no previous illness.
Believea heraelf near the full term of pregnancy. Foot
months ago began to suffer with crauip in tlio legs, and
then the legs began to svrell, and tho swelling has since
continued and increaeed. Has had no pain. No vomiting.
Appetito moderate, bowels confined. Has slept well. Ho
headache. No defect of sight.
On admission. — Patient was well nourishod, but anasmic.
Legs and lower abdomen were osdematDus. Cardiac dol-
nesa increased, but no mnrmar ; pulse 75. Nothing ab-
normal on ophthalmoscopic examinalion. Abdomen greatly
distended and flnctuatring. The urine, when albumen was
precipitated, became nearly eolid.
Dr. Herman saw the patient on May 22nd. Tho os
uteri waa then tie size of half-a-crowD, and tho head
could be felt presenting. The patient did not complain
of pain.
May 23rd. — Still no pain. Os uteri same size. Fcctai
heart beard, over 150 per minnte.
26lli.- — Couditiou tlie same. Tiio following measnre-
menta were made : — Circumference at umbilicus, 47 inches;
ensiform cartilage to ambtlicus, 12{ inches; pubeg to
nmbilicns, 9^ inches. At about 2 p.m. the membranes
*CY WrrB URtOHf'fl DTI!!
32?
TTcro soparated by the finger as far round the os ateri as
tho fingor could reucb — tbat is, about 1^ inclins. 8,30
p.iD., patieat delivered of twins, living, both males, Mucb
hfflmorrhage. Much liquor amiiii. After delivery tbe
cedema rapidly subsided.
30th. — An attack of dinrrhoeB.
June 6lb. — Pfttieut jesterdaj and to-day complaining
of headache and loss of appetite.
8th. — Urine again contftius as much albumen sa ou
admission ; no casts. Headache gone. Appetite had.
Liver dniness to fifth rib above, to costal margin below.
Splenic dulnesB not larger than four fingers' breadths.
lOtL. — The urine contains a good deal of pus, although
the catheter has been but seldom used.
Mth. — Patient gaining strength rapidly. Is now
allowed up for six hours daily. No pain. No cedema.
Takes food well and sleeps well. Children healthy and
strong.
22i)d. — Patient allowed up all day^and to go into garden.
'28lh. — Discharged.
The alterations in the patient's diet are sLowo in the
ch&ri.
I have cndoavourod to trace the subsequent history of
tiiis patient, but have failed to do so.
Temperature. — This was normal on admission, and con-
tinued so until the fourth day of the lying-in, when it rose
to 1 01'2°. It fluctuated between this level and the normal
during the next eleven days, but no causo was discovered
for this excepting an attack of diarrhoea which accom-
panied the first rise of temperature. During the last five
days of this period there was a return of the albuminuria,
AS will be snbsequently described. After this date the
temperature did not exceed 1)9'6°.
Urine. — Instructions were given that all the arine
passed by the patient should be saved. As far as pos-
Bible this was done, though some was of coarse tost when
the bowels acted. The patient was allowed to pass it
herself as a rale> but at intervals some was withdrawn by
innninwiifli
wssamn
DiBi ■■■■■■nniiinBi
I
PBIOSAITOT WITH BRIQBT 8 DI9EABB.
831
tfao catheter to make sure that tho characters of the arino
were not materially altered by admixture with lochia.
The numhsr t>i motionB is shown on the chart, so that
the amount of error from this cause can be roughly estt-
matod.
Quantify .—Until delirory the quantity of nrine was
below the average, but under the influence of rest and
inilk-diet was increasing slightly ; 22 02., 24 on., and
28 oz. are the amount;^ For the three consecotiTe days, on
the last of which the pntienb was delivered. Delivery was
followed by great diureaia, 118 oz. of urine being passed
in the twenty-four houra following delivery. During the
next two days the qnantity of Qrin.o was atill more above
tho avorngo, 136 oz. and 130 oz. being collected. Then
oomM apparently a auddon drop to 56 oz. ; but as on
thifi day the bowels acted 6ve times, it ie probable that
had it been possible to onllect all the urine, the dimiiiution
would not hare been bo great. I think there would have
been a diminatioD, for on the next day, the BEth of the
Jying-in, all the urine wa« collected, and amoauted to 80
oz. After this the quantities of urine collected each day
do not depart widely from the normal. They are on the
whole rather below it, but this is on some days accouDted
for by loss accompanying tbo action of the bowels.
Specific gravity. — ^Tho specific gravity varied as a rule
inversely with the quantity of urine. Before doli\"ory it
WM 1024, 1031, 1026, and with the great diuresis which
followed delivery it fell to 1012 and 1011. Further com-
ment will be rando in connection with the urea percentage.
AJhumen. — On admission the urine contained four-fifths
of ite bulk of albumen, and during the two days preceding
delivery became solid when the albumen was precipitated.
On the day following delivery the albumen dropped to a
mere trace. On the tenth day after delivery the quantity
of albumen increased, and on the eleventh day the urine
again contained four-fifths of its bulk of albumen. This
continued for four days, and then the qnantity of albumen
Again began to diminish, and by the twentieth day after
332
PREQKAKCT WITB BRIOHT'8 DtSEXSB.
(3flivi>ry tliere was again only n trace of albumeii present,
Tliere was no accompanj'ing' change in tlie patieul'a con-
dition or circnmstiLtices which appeared sofficient to explain
tins temporary increase of albumiouriH.
On May 26th, when precipitation of the nlbumen
rendered the nrine nearly Bolid, the para^lobuHn was pre-
cipitated with sulphate of magnesia.. After subsidence tt
occupied about three-eighths of the tcst^tabc- After
eeparation by filtrntion of the paraglobolin the seram
albumen precipitated amounted to about half the bulk of
urine. May 29th (fourth day after delivery), about half
the albuminous precipitate was found to be paraglobulin.
June 11th (the first day of the temporary increase of
albuminuria abova raenbiooed), aboat iwo'thirda of tbe
albuminous precipitate was found to consist of pai-aglobulin.
Urea. — The amount of nrea was estimated by tho
RuBsell and West hypobromate process. In order to uttain
tho most acouratc results possible, tbe same specimen waa^
sometimes tested both by the RusbcII and West process
and by the Liebig process. The results of this complk-
rison may be interesting.
Thti «iliin[LLc wu nut madtt
till two dajH Mftpr ex«mi-
iiatimiVjytlin ItiiMcll-Wn»t
procoss, &Dd tha nriae hod
bcgnn to decompuee.
The corvc indicating the percentage of urea followa, in
the direction of its variations, that of the specific gravity.
But before deUrery, the urea-percentage was below whai
would have been expected from the specihc gravity of the
uriue, while after debvery it was higher. On admission
the percentage of urea closely ccrreaponded to the specific
gravity, tho latter being 1024, the former 2'2. Chi the
following day, though the specific gravity hod risen to
DaOa.
BDuell-VeiL
UtMf.
Jane 3
S5S
309-5
.. *
360
342'9
.. 8
3ia
i'JS
»io
676
MB.
rRlOHASCT WITH BBIOHT'f DlBtASB.
833
1029, tlie urea-percentage was only 1-6. Ou the tlay of
delivery, witli ft specific grairifcy of 102(3, the urea-peroent-
Rge Itad further ileclineil to I'o. Then comes delircry,
and with it a rise in the percentnga of urea. The 118 oz.
of nrine passed ia the dfty following delivery, showad
1012 specific gravity R-nd 1-45 per cent, of urea. During
the next three daye, the percentage more closely ap-
proached the specific gravity, as the following figares
show : —
Sp, ir.
UrFi-iMrreBUgS'
taid»j
<■«
1011
IS
Srd .1
t*a
lOU
la
Ml ..
...
1018
i-i
bcgina to
rise
again : —
Up. V-
Umi-pcrraitt|D.
6tlL tUj
1011
1-3
eu) ,.
1012
l-3(
m ,.
1018
1-0
8til „
lOSl
8-6
Ml H
i«r
a-6
The rise in the specific gravity and in the percentage of
urea followed the addition of cgj^st to the milk diet. The
temporary return of the albuminuria, which has hocn
rcUtcd, was accompanied by still more transient depres-
sion of the specific gravity and iirea-perccntngo. On the
second day that the urine was again Inarlod with albumen
the specific gravity was (024, the percentage of oren 2'7.
The specific gravity and urea-percentage had risen to their
former standard before the albuiuiouria had notably
diminliheil.
The total qnantity of urea was on the day of adiniKsion
little below the average of health. On the two following
days it sank to 180 and 245 grains respectively. After
dolivory it suddenly ran up to over 800 grains. After
this the quantity gradually declined till it approached the
average of beolth. The temporary incronse in albumin-
uria was proccdcd accompanied with slight depression of
834
PKEONANCT WITH BRlGHt's DIBEISI.
tlie daily quantity of urea. After this had subsided, the
daily urea excretion sgaiu ran up to over 500 graina.
About; the end of the second week of lying-in cy&titig
CAQie on, Siud the nrine soon became smmoniacal. The
diminution in the amount of urea which the chart shows
at the end of the third week of Ijingf-in is partly aooouDtod
for by decompoeition.
Deposit. — On admission the clinical clerk found some
hyaline and granular casts in the urine. How many is
not recorded. On snbseqiieut examinationB very few or
no casts were found. Dr. Turner examined carefully the
urine passed on May 26thj but only succeeded in finding
one hyaline cast. On June 6th two casts were seen :
none between these dates, although sought for. None
were found again till Juno 27th, when two hyaline casta
were present on the slide.
The urine did not at any time contain sugar.
This case seems to me of much interest from the marked
effect which followed the lessening of the intra-abdominal
pressure produced by the expulsion of the abnormally
great uterine contents. During the three days wh.ioh
followed delivery, the quantity of nrine, as compared with
the three days immediately preceding delivery, was qaio-
tupled, and the excretion of urea tripled. After this the
quantity of urine and urea gradually fell to the average of
health. Diuresis after delivery has been described as a
feature of normal lying-in, but not to this extent. It seems
as if the abnormal proBBure had hindered the kidneys in
their work, and that after the removal of this pressure tha
kidneys, so to speak, tirstr exerted themselves to clear oft
arrftara, and then returned to their ordinary functional
activity.
The same sadden diminution in albuminuria as has been
observed in many other cases, was observed here. The
albumen was largely paraglobulin, a fact which supports
the views of llalfe and of Magnire that it is this form o£
albumen which is abundant when albumianria is due to
increased pressure.
P810NAMCT WITH BKJQHt's DISEASE.
335
I may also call attention inciJeutallj to a minor point,
vis., tlie effect of separating the membranes in stimulating
ut«rine action.
Casi 3. — Surteentk pregnancy ; jfiis after confiijemenl
tia yeara previously; symptoms at beginniyig of eighth
month of jircj/nanct/ ; intra-uterine death of fcetus ; prema-
ture labour induced at end of eighth rmyiith^ after one week's
treatment bjf rett and milk diet ; no diminution in quantity
of urine, bvt dimivished urea-eliminat-ioti ; albtiminuria ;
ditninution of albuminuria and partial reMoratiun of nrea-
excretion hufore deliver>f, and continuincf after delivery;
recovery, but persistence of renal disease (reported by Dr.
H. G. Ly», Resident Accoucheurj and Mr. F. S. Harris,
Clinical Clerk).
A. G—, aged 36, admitted March lUli, 1889.
Patient ia a Polish Jewess. 81ie came to hoapital on
account of enelling of face and legs. Said sho had had
DO illnees except in connection with pregnancies. Came to
Eogland at the ago of twenty-two, and had since then lived
in the East-end of London and worked as a tailor&gs. Had
Qocasionally been so badly oEf as not to get enough to eat;
Qsoally worked twelve hours a day.
First meDBtrnated at sixteen. Catameniuregntar, except
during pregnancy, and generally without pain. Was
married at twenty-two, and has had fifteen pregnancies.
Five cndediu delivery o£ living children at or near term,and
ten in miscarriages at about three months. 8ix yeara
ago, after a conliiieraont, she was very ill with " fits."
Now thinks herself eight months pregnant. Until throo
WMkfl ago felt the child'A movemeuts. Throe weeks ago
her face and legs began to ewcH, tbo eyelids first. For
the same time she bn^ suffered from severe and constant
headache, has slept badly, and had a cough. Has only
vomited once. Has pa-is^ed much urine.
On admission the urine was clear, free from deposit,
sp. gr. 1018, and containbg one-fifth albamou. Patient
was put OQ milk diet.
383
PBtSKAVCT WITET BBIOEl'S DlBEAfi&l
March loth. — The following note was made : — PaU
is somBtvliataQiBniic ; faCe puSy. C&rdiac dulaeaBnwl
on the right to tbd middle line, od tho loft to a fingdr*
breadtli beyond the nipple ; no nnirmnp. Slight oodem
of feet. Arteries very hard. Fundua ut^ri reaches no
quite halfway between umbilious and ensifnrm cartilage.
Cervical canal not admitting finger. Cervir TiaB been
deeply lacerated to left.
17th.— A flexible bongio was introduced into the uterus
for its whole length, and left there.
18th. — Patient delivered about midday of Adecoroposing
(cetus. Presentation by the breech. Delivery of the head
vaa aeeisted by tractiou. No excessive baQniorrhage.
15th. — Ophthalmoscopic examination shows neuro-
rctinitie and white patches in both retiniD,
April 3rd. — Patient put on fish diet.
8th. — Discharged. Feols quite well. No oedema.
Appetite good. Sleeps well. Trace of albumen still
pi-esent.
Temperature. — This calls for no especial remark, as (fc
never exceeded 100°.
Urine. — Inatractioas were given that all the urine passed
by the patient should be collected and measured.
Quantittf, — Taking into consideration that some urine
was lost with the iDotions, the quantity of urine waa
slightly above that which is nsually regarded, as the average
of health. The amount averaged 43 07.. per day before
delivery, 42 oz. per day after. The boweU acted on the
average once a day before delivery, about three times in
two days afterwards. On the day of delivery the amoimt
collected was larger than on the days immediately pr
ceding and following, which looks as if some diuresia
followed delivery. But, on the whole, the variations in
the quantity of urine do not seem large enough to ba
important.
Specific gravity. — Thia ranged from 1012 to 1020. I
shall refer to its variations in connection with tha per>
coutage of urea.
SS8
PBBOH&KCT WITH BBIORT 8 IJI8KASB.
Alhumev. — On admission the uriae contained one-fifth
of its bulk of albumen. The amount nt albumen began
to diujiuisli after five days' treatment by rest and milk
diet, and before delivery bad tdkeu place. After delivery
the diminution continued, and iu a week had sunk to a
trace. Throughout the rest of the patient's stay in hos-
pital the ui-ine contained either only a trace of aLbumcu
or none at all.
The relative amounts of serDm-albumen and para>
globulin were unfortunately not ascertained.
Urea. — The percentage of urea on admission was below
that which would have been expected from the specific
gravity of the urine, the former being '9, the latter 1012.
Daring the five days preceding delivery the BpeciBc
gravity of the urine diminished ; bnt during the last two
of these days the percentage ot nrea increased. After
delivery thn perceutagc of urea still further increased,
reaching its maximum (I'G per cent.) on the sixth day.
After delivery the percentage of urea carve shows a
rough correspondence with the specific gravity curre,
which it did not before. The increaac in the percentage of
urea distinctly coincidoa with diminution in the amount of
ulbamen. Thetotal nroa-cscrett on shows a marked incraaso
after delivery as compared with tliat before delivery,
although the patient's diet was unchanged. Tlie urea
eliminated before delivery averaged 156 grains per day.
After delivery it averaged 269 grains daily ; althongh, as
has been mentioned, more was probably lost with the
motions than before delivery. There was no deposit from
the urine. Casts were not found. They were looked for,
bat I am unable to say how often. The urine at no time
contained sugar.
November I9th, 1889. — Four weeks ago patient had
what she thinks wn.s a mtscarrifige. Says that she fcoU
very weak, and that her head soems confused. Three
months ago she hbd what she calls "con^Tilsion fits;"
this statement her friend who is with her confirms, and
says tbey were attributed to indigestion; but neither can
PRKOWANCT WITH BBIDHT*B niSKASr.
3M
give a very clear ncoount of the fits. Has had no vomit-
ing. There is nlight cedema of right leg, none of face.
Appetite moderate. She is anfemic. Arteries very hard,
RetinsB show spots and patches, the results of old liBetnor-
phttge. Uriue (drswn with catheter) sp. gr. 1009, contains
OQe*tentKoE alliiimen, mainly serum-albutnon, only a traco
of paroglobnlin.
December, 1890. — Urine contains { albamen, and gives
a depofiit containing pns-cells, and a few epithelial casts.
This case difEors from that which precedes it in somo
important particulars. There was not such great abdominal
distoneionj the uteras being rather amaller than would havo
been expected from the patient'H account of hor period of
pregnancy. There was no marked diminution in the
amount of urine before delivery, nor marked diuresis after;
and the change in the amount of urea eliminated was not
80 great. Unlike the other three cases recorded in this
paper, and unlike meet coses of ecIampsiBj the urine,
instead of being almost solid with albumen, only contained
about onc-fifth. As in other cases, the effect of treatment
by rest and milk diet n-as to diminish the amount of th^
albuminuria, and the effect of delivery to dimiuish it
stiti further.
The urea-excretion was much below the average when
the patient was admitted ; it rose under treatment by rest
and milk diet, and still further rose after delivery ; h\^b
throughout it was below what is regarded as the average
of health.
I may point nut aleo that the symptoms in pregnancy
were more marked than in the other casea, and that the
disease persisted nearly two years afterwards.
The reading of the fourth case wa« adjourned nntil tho
following meeting.
NOVEMBER 5ib, 18D0.
Alpked h. Ualabin, M.D., Frosideat> in the Chair.
Present — 4! Fellows and 3 Visitors.
W. U. Laarence Copeland^ M.B.Cantab. ; HaroM Low,
M.B.Cantab. ; Frederick Johu McCauii, M.B., C.M.Ediu. ;
Harold Burgcsii Osbura, I/.B.C.P. ; Samuol W. Wbeaton,
M.D.Lond. ; and R. Muzio WilliamSj M.D.Lond.j were
udmittrcd Fellown of tVe Boctcty.
Richard Ackerley, M.B., B.S.Oxon. (Asbbiirton] ; !D«vid
Berry Hart, M.D.Edin. (Edinbnrgh} ; Charles David
Green, M.D.Loud. (Upper Edmonton] ; John William
Taylor, P.R.C.S. (BinninghBm) ; and Kdwiu Francis
White, F.U.C.S. (Patney), were declared admitted.
The following gentlemen were elected Fellows oE ibo
Society : — John Dysart McCaw, F.R.C.S. (East Finehluy) ;
Hagh Jones Roberts, M.R.C.S. (Peuygroeij) ; aud Ueory
Bartlctt Shillingford, L.S.A.
The following gentlemen were proposed for election . —
Thomait S. Allan, L.R.C.F. and S.Ed. (Tonbridge) ;
Skene Keith, M.B., C.M.Edic. ; Kdgar Ashley Lubbock,
L.R.C.P.Lond. ; John Reynolds, M.D.Brox. ; aud Frederick
Sloman, M.R.C.S. (Brighton).
542
5E OP TUBAL ABORTION.
By J. BiAND SurroN.
In Mny, 1890, I saw in cousaltation with Dr. Clegg, of
Htratford, Mrs. N — , aged 26 years, tlie mother of two
cbildreiij the youngest being six yeRrs «ld,
The patient complained of great pain in the lower park
uf the abdomen. The pain commenced enddeutj three
days before I ttaw her, and was acouinpaniod by a fruo
disoharge of blood from the uterns. Thu cutamenia had
been quite regular during the last four years.
On examining the abdomon no swelling could be de-
tected. The left breast was slighWy enlarged, and milk
could be easily squeezed from it. There was no difficulty
with the bladder. On examining the pelvic viscera a
rounded, moveable, tender swelKiig could bo niiide out on
the left side of the uteruSj and a similar but larger Gwelling
on the right side, but this was not tender. The patient
was admitted to the hospital next day, and Dr. Boxall
kindly saw the case with me. He suspected that it was
a retroflexed gravid uterua. Iq order to settle the dia-
gnosis chloroform was a-dminiateredj and Dr. Boxall
pushed the swelling on the left side upwards into the
abdomen. It was than found to be distinct from the
uterus, which was clearly not gravid. In the afternoon
the patient complained of severe aching pain in the back,
and had a very thin pulse, and at 6 o'clock the tempera-
ture rose to 103°. It was clear that some mischief bad
been done to the tumour. Next day I opened the abdo-
men and found the intestines swimming in blood. I
aeiaed the left Fallopian tube and drew it upwards. It
was enlarged, tho OBtium widely diluted, and coutained
olots of blood. It was trausOxed with silk, tied, and
removed. On examining the right side an ovarian oy&t
TUBAL AUORTIOK.
345
of the size of a targe orange was found and removed in
the usual way. The blood iu the peritutieal cavity was
now washed ont by means of water ab 105°, a.ad the wound
c'losud. On the evening- following the operation the tcin-
porutura rose to 102*, tht-u slowly tell to normal ; cou-
valescenco was uninterrupted, and patient left the hoepitul
fourteen days after the operation.
On examining the parts removed at tie oporation I
found the right ovary occupied "by an " oophoritic *' eyst
(Fig. I), cootatiitDg fluid largely charged with cholesteriuo.
AecciIOflY OSTIUM
-TUBE
OSTIVM-
PABOVAff tUM -
j-V
-^
Fii>> 1.— OvBriAn eytt o( the ri|;Iit tide with an nccMtory oitinin
b< tliv tub«. (CW of Mr». N— .)
The Pallopi&a tttbo, &s shown io the drawing, presented
an accessory ostium, a not infrequent anomaly. The nto-
hno portion of this tube was uuuijually narrow, tbe corre-
S44 TUBAL ABOKTIOK.
Bpotding portion of the left tube was also very nnrrow,
bat its ampulla was congested and dilated to llio thick-
ness of the tlitinib. Its oBtium whb wide and patent. A
rounded firm body as large as the kenie! of a cob-nut was
felt within the tube. Ou slittiug up tlietnbp, this rounded
body was adherent by a small portion of itscircamference
to the tubal inacouB membrane. The free portion of thia
body presented numerous small villous processes ; its iotc-
CHOMflHK V|L
TUBE '•^^ t^^t^J^, //(
M>DPIBGTIC BVU"!
\^i
Fie. 2. — The left tube of Mrs. N — opened to expose the it^pleetie ovuw.
riorwaa occupied by a small rounded cfLvity which contained
fluid, and the walls were lined by a delicate membrane.
Portione of the wall were removed, hardenedj and esamtned
with the microacope. The sections consisted of blood-
clot, mingled with chorionic villi. Thus the raaorosoopic
uud microscopic characters showed clearly enough that
l^OBAL AfiOBTIOH.
345
this ronndod body was what is called hy obHtetrtciiLtiK an
"apoplectic ovutu." The term signifies an orum in which
blood has been extravasated icto its membranes and
chorion.
The mucouN membrane iu the adjacent parts oF the
tube still retained its epitheHum. The cori'esponding
Qvarj waa enlarged, cVHtic, and contained a recent corpus
luternn. The diaaectiou of the parte cleai-ed up the nature
of the case. Thia woman had an impregnated ovum re-
tained in tho loft Fallopian tubo. At the time she was
seized with sudden pnin, the ovum had become partially
detnehod and tbe tubo distended with blood. When this
tube was pushed out of tba pelvis fresh liafinitrrhago was
caused, probably through further dutachnieiitof the ovum
m-
'^\
<
■*^
'^;
PlO. >■ — ^Th« ovaa im Mm. IU nfttnnl ilw \» >howa in Elg i.
from the tubal mucous membrane. This is the third time
in which I have found aa apoplectic orum in cose&of tubal
d46
OVJlR¥ and TtJBK WITH CAPILLOKA.
pregnancy among tho examples oE ectopic gestation OD
which I have been called upon to operate.
I first called attention toibe formation of an apoplectic
ovum in tuba! pregnaQcies iu 1889. Recently Karl Kt?ller
and Ortlimanu liave publishod in ' ZeltscbriEt fiir Guburts-
hfltfe,' Bd. XIX, a eeries of cases in wliich the ovom in
the tube was converted into an apoplectic ovum, Keller
reported three cai^es, and Orthmann ten ; these cases con-
firm my observation in every particular. Keller's paper
is very interesting, and he points out that tubal pregnancy
may bo ai-reated either by rupturu of the walls of tho ges-
tation sac or the expulsion of the ovum into the peritoneal
cavity through the abdominal ostium ; this last he terms a
tubal aho7-tioH in contradiatiactiou to the escape of the
ovum through a rent iu the tube.
In order to make the case as complete ^ possible, a
magnified view of the ovum is shown in Fig. 3. Many
of the aectious were carefully esamiufid in the hopo of
finding some traces of the embryo, but with a QCgativo
result; it secme to hiiTo been dcstroyod by tho hasmor-
rbage.
Dr. Gbiffitu staled an liia opiuiuu that hcetuorrliago into the
cboriou was found in vnryiug degreoa in every vane of oitm-
uterine gestation iu wht<r(i rupture had taken pl^e, aod that
wliilat liieiiiiorrliage miglit in Bome cases be tlie L-ause of rupture,
it WBB undoubtedly more often the result.
SUPPURATING DERMOID CYST.
By W. Ddkcan, M.D.
OVARY AND TUBE WITH PAPILLOMA.
By W. DuMUAH, M.D.
847
CASE OP ACEPHALOUS ACARDIAC TWIN.
By Amakd RoDiB, M.D., B.8.
Tois specimcD of accplmlous acardiac twin was pro-
Hvutod to Ctiaritig Cross Uuspitnl sotno months ago by
Dr. Gibson Berkley, "who acted as accoacLour at its birth.
It had remained in spirit till iafit week, when Dr.
Lubboclc, the curator of the raosenm, asked me to write a
description of it for the cntnlogiie. It is by these gen-
tlemen's kind pennifision that I am allowed to show it to-
uight.
Dr. Gibttoa Berkley states that it was uue of twins,
both fciiiulu, and tliiuks (though aa interval of some
monthn has olapncd) that there were two distinct placeutce
and cord^.
The womau was a mullipara, aud lliu aciirdiac twiu was
born first. The normal twiu was but ono-tbird of the
proper size, and lived only three days.
Tbu s})ecimen is a ^oud sample of the acephalous variety
of fcetna acardincus, marked by arrented development uf
tho viscera and extreme oedema of the enbcutaneous
oounectivo tissue.
The external genitals are tbose of a female, and the
lower part of the vagina is patent. The unas is aUo
present, and the ri>otum is patent throughout.
The difBcnlty in dissecting such a specimen ae this,
wbick had been imtnereed in spirit for a year^ was great,
and I was very glad to avail myself of the gi-cater expe-
rience of McBsrs. Bland Suttou, Alban Doran, and Dr. W.
S. A. Griffith. The first very kindly enabled mo to identify
many of the points of interest.
There appears to be no trace of the head. The upper
limbs are represented by the clavicles, and a. nodule of bone
which appears to be the head of a left humerus. The
846
ACKPHALODB ACABDUC TWIN.
Hpinal coIiitiiH, sacrum, and ribs are present, and the
sternum ia represented hy an irregular tnasB of cartilage.
TLe pelvia and leg bonea are fairly well developed.
All umbilical Iiernia protrudes nttlie navel, and the cord
is seen on its right. By making vertical iuci&ions through '
the oDdematouB tissue in tbo two nipplc-lincs and rofloct-
ing the intervening integument tipwards from the pubic
arch, L'oila of iiitestiuo are soon and can bo traced upwards
to the hernia aud downwards to the rectum.
On eitlier side, leyel with the brim of the pelviii, is a
genital gland, presumably an ovary. The vagina appears
to end in a cut-de-sac. No uterus is distinctly seen. The
bladder, with a patent nrachns, in tamed np with the
reflected intcguuient. Two lobulated kidneys, lying iu
contact iu the middle line, are very dititinot, and ono
ureter can be traced down to the true pelvis, There ia
a Eomewhat creeccnt-shaped body lying above the kidneys
behind the ribs, which is poseibly the heart, and a vessel
representing the aorta ean be followed downwards.
Behind and outside this visceral space are two largft'
spaces with a membranous lining, containing a subatanee
which rosemblea the tissue of tho choroid plexus of the
lateral ventricle of the brain ; but the position of the
spacee, posterior to the neural arch, point more to acci-
dental cysts than to any developmental significance.
Mr. AiBAlt I>oRA.>' could not feel Botisfied that a rudiineatary
heart eiistcd. A trace of a heart waa usually seen in acardiacus
paracephalu?, where rudiniC'Dts of the Lead were pretout. This
condition wae figured iu his own Bkeitcl) of tho (pecimen in fit.
George'H HuHpital Aluseijm, which accompanied hie ootea OD Hr.
Treatrail'B B[]ef.-imeii of niyUi-epbalous acardtac twin in vol. xizi
of the Socifty's 'Tranaactioiift.'
The specimen waa referred to a committee consisting of
Dr. Amaod Routh^ Mr. Bland Suttou, and Mr. Domu.
349
FOUR CASES OP PaBGNANOY WITH BRIGHT'S
DISB.A8B.
BjrO. Kkkest Hermak, M.B.Lond., P.R.C.P.,
OUTBTilC fllTtlCIAV TO vau IX)!(IiOl' BOlPtTAU
(Coniinued/hun ^age 3»1^.)
Ci9E 4. Albuminuria ; wrffmir f.witehinga ; et^ebral
hfcmorrhage ; induetion of labour at beginning of eighth
month; (kild living; diminished urea-elimination before
Heliverif ; after deliwnj rapid inereanp in pprcentage of
vrea and tanjiorarg divUntUloji of albuminuria ; reneiecd
cerebral hieinorrhage ; coma ; death ; ntj aatopny. — Tliis
cue in iucumplutc iu maQy re.<4pcctH, bnt tho recurdH of
tho urine are intcrciiting. (The notes were tftken by Mr.
K. A. K*ihineon, Clinical Clerk, under tlie superrision of
l>r. W. J. Httdley, Resident Accoucheur.) R. B — , set. 41,
admitted into Victor Ward, London Hospital, January
28th, 1880. No prpvioua history could bo obtftinod, the
pntient boiog UDnblo to givo one.
Janonry Slst.— Tlio folloniDg* note was made. Patient
iit thfn bat not anaemic. Speech thick and diiBcuIt to
underistand. Slighb bilateral muscular twitching^. Puke
har*l, arteries thickened. Heart's apex below sixth rib
and just internal to nipple; no murmur. No cedema.
Utertia reaches not qnite hnlfway between ambilious and
ensiform cartilage ; fcctal beart audible. Ophtbulraos-
oopic cxaniiaation shows nothing abnormal. Takes food
well. Patient is undorstood to say that she has of late
bad a severe headache every evening, but hao ■
Has had vomiting ocoasionally, but not
850
MlBONAJfCY WITH BBIOHT'H DIBlAmi.
plains of bad cong'h. No abnormal signs In lungs other
than bronchial r&les,
In the afternoon and evening of this day, right hemi-
plegia with aphasia gradually came on.
February let, 3 p.m. — A bougie put into the ntoms.
9.15 p.m.j pains first noticed.
2u,d, 1.30 a.m. — Patient delivered naturally oE a living
child, male. Not much haemorrhage. Ergot gtreo after
delivery.
8th. — Patient's condition has gradually improved, para-
lysis lessening, speech retapning.
After the last noto waa made, coma gradually came on,
and patient died on Febmnry 10th, at 9 a.m. No autopsy
was allowed.
Temperature. — This never exceeded ^9", and before
death became abnormal.
Urine. Quantity. — It was only measured on two days,
January 28ti and 29th. The quantity was helow normnl,
being \% oz. the 28tb (once lost with stool], 23 ok. the
29th (twice lost).
iS^)eri/(c gravity. — Here the reoord is also imperfect:
January 30t]i and 31st it was 1020; February Jut, 1012 ;
4th, 1030 ; 5th and 7th, 1026 : so that the specific
gravity rose after delivery.
Albnwen. — On odtnisaion the urine contained half its
bulk of alhumou. This continued till February 2ud (day
of delivery) whou it sank to one-third, and February 3rd
to one-fourth. After this it increased again, 6o that on
February 5th the quantity was the same as on ndmisxion.
Delivery was thus followed by a diminution in the quantity
of albumen. February 9th, the day preceding death, the
urine was nearly solid with albumen. On January 29th
and on February 9th the paraglohulin was separatetl from
the aeram-albumen, and it was found that the albumen
was almost entirely serum-albumen.
Urea. — Before delivery the percentage of urea was less
than the average, and less than would have been expected
from the specific gravity oE the urine. In the two days
PBMSftNCT WITH BBtOHT'S DISKABR.
351
following delivery it rose to more than double what it had
hecD, aod more than would Lave been expected from the
BpooiGo gravitj. Duriug tlie four days preceding delivery
it averaged 1'3. On the day after delivery it was 1-9,
and during the eix following- days it na% 3" 15. The
figures follow :
Before delivarg.
Jan. 29= 1-3
„ 80= W
„ 30=1-4
Feb. I =1-1
Dag (^ delivery.
Feb. 2=l'fi
4/ler JBlivefji.
Feb. a- 10
.. 4=31
,. 6 = 3-6
„ 6 = 8-2
., 7 = 3 1
„ 8=3-5
„ 9= 80
Deptntii. — Before delivery, the unnc contained epithelial
and Fatty casts. I liavo no noto of the deposit subse-
qaently. No sugar was found in the urine.
I publish this case because, like the others, it exhibits
rapid increase iu the urea-perceiitage following delivery,
and aleo dimiuution in the albumiuuria.
It would be premature to generalise as to the mutual
effects of pregnancy and Brigbt's disBaiie from these few
oaseH. But the phenomenii upon which I have commented
show that there are such effects. The study of the detaiU
of cases ia the only way of attaining definite knowledge on
this subject, and therefore I have thought thi'se cases
worth bringing before the Society.
Dr. Lettk NiPiEs t&id that the ca«eB recorded by Dr. Herman
were a Taluable nddition to the knowledge alrendy poKsoKted
regarding kidney dlneoiie in pre^^nancv. DLriug gestation there
was a specialty unstable eonoition of the epithelial i\»tno in all
the targe slandF, nnd, as might be expected, thp kidacys fre-
Suputly sunered. Dr. Herman'R ra«OH wero illuEtrative of the
act that (li»tiii<?t rpnal dj»cABe might esilt in pregnane; without
any aubBcqucnt ccinmjjBin. Twenty-five jeare ago SevftTl, of
Prague, showed tliat. of ii«TentT patients auffering from kidney
dtBCAfle duriug geatnlion, only two developed eclampeia. A mors
recent icrieH of 152 caves, in which autop^it-fl were made on
Ju«r[wral and pregnant women wlio were found to lutve Bright'*
iseaae, sbowed that unlj tl'Sper cent, had eclamptic tymptoma.
852
PRROlTAlfOI
tBlOBT^S DtaiASf.
BtiTnbprger in tlint series included acute chronic and fttrophje renal
diacase. Brn.uii> who hae douv more tbaii aayoii» else to conmct
iirasmia with eclampain, estimated that GO per cent, of vomen
suffering fToni acute aud chronic Bright'H disease woald develop
conviilaivu». Spiegel berg, who most warmly espouBsd tbo
urermic origin of eclanipBia, admitted that some catiea could not
be accounted for by pre-exigtent kidner disease. 8oiiie years ago
Dr, Leith Napier had mentioned cases of chronic kidney diseaso
in pregnancy which were not asaociated with eclampeia. He
referred to one very highly illustrative case in which, altfaough a
pn?gnant woman who bod contracted scarlatina and thereafter
aufi'cred from ^ery well-marked nephritis, the pregnancy con-
tinued, and when, eoine months after, she was delivered, there
was not the alightosl interruption lo a favourable recovery. Ho
regarded tlie eetimation of ui-ea and albumen as of great import-
ance, but 1)0 thought we required furthef iaformalion than w©
yet posHessed, ae to some points on which he would like to s«k
Dr }lerinfln'a opinion — What waa the normal amount of urea
exi ruted during pregtiuncy ? Viae it greater or leai than in the
nun-pregnant ? Dr. Napier believed it to be less, and that there
waa almost invariably increased elimination after parturition.
As to albuuiiuuria, this oci:urred so very Ire^uently in pregnancy
from well-recognised causes, aud was often so temporary in
clmracter that, uuloaa we had other evidences aasoeisted, wu iDtist
Qot attach too great importance to it. He thought thatall albu-
niinuries. whateverwas the cause, were reltevedal'ter parturition.
The eiisteuee of acetonuria m relation to eclompRia wan of tome
impertftDce. Le'corchi^'and Fclilingt i^ud also Dyers hod recently
directed attention to thiN. Had Dr. Herman made any observa-
tions bearing on this point?
Dr. C. U. F. HouTH admitted he was labouring under tl .
disadvantage of not having heard detaile of Dr. Herman's Gnt'l
two casca, but he had lizard the detaila of the last two and read
the abfitracta of the remainder. He did not think that they
eliould be called casea of Briglit's diseaaB merely because albu-j
minui'ia was present. It was well knuwu that albumiDurin oftOD
resulted from the pressure of tumours, such as ovarian cysts and
uterine filbroide, on the kidoeya. On the removal of theee tumoura
the albuminuria disappeared. The same waM frequotiL in preg>
nancy. Now he believed that unless caats vern found in tho
uriue likewise, and unless by tbo use of the ophlhaluiuseope
eiideiicea of neuritis and local congeation existed in the eye, we
had no right to diagnoHC those cases us Brigln's disease. He did
Dot gather that in any of these cases, except the third, the usual
opIithalmoBcopic signs were observed. lu thia caee the signs
* ' Annnlc* do Qyn^iwlaglc,' Oct., 1880.
t • Pliysiul. a. PutbuluKiu dn WiK'livubutU,' Stuttgart, 1800, p. ItU.
PEEONAJfCT WTTB BBIOHt's DISBA8E.
wore jtrcneut but vaniHlitd after dulivL-ry. Puerperal coiivulsicius
produced by Briglit'a diEeaBe were c'H|)aI)l« uf being a^rrealt'il by
remoral of the pressure on the kidneys ; this fact was proved by
tbc cessation of the dta after delivery to moat e&&ea. Moreover,
be remembered one case of terrible convuUions occurring every
tea or |{rtci:<ii miiiutPM, oue of l)ie wor^t he ever »aw, in which he
•nut called in, nod where in attempting to deliver bo found pro-
inpse of the cord. This he reduced on Sir JnineB Simpeon's plan
by putting the pftticnt on her belly. The momont this was
effected the convulaions stopped and did not recur. It was to be
iiiuleretood hair even iu h case of Bright'e disease, however olight,
SreHHure might teinpurarily iucrease> the kidney trouble, and pro-
uc« convubioiiB; md heiiw it was snfe prnctiCQ to remove prea-
•uro in all caAee by putting the patient iu a prone positioii.
The result proved how much nas due to presaure of the super-
ittoumhent tumour or child.
Dr. UaTEs ipoko of the treatment of such cases. Coueidcnuf;
the gnire danger the woman was incurring (indeed, the daujjur
increased generally as the gestation advanced — at atl events this
was so in later months), he thought tlia-t prematuvo labour
should be bruiiglit about much earlier than was cuetomnry.and
not infrequeully artificial abortion. The fa>tu«'s life wag gene-
rally compromised, it not seldom died, or was expelled too young
to survive, Pronounced albuminuria should, lu hm opinion,
always raise the quesliou of early t«rmiiiHtton of thi^ gestatiou.
In the present series of four <;as«s one mother had diod, in two
tbu albuminuria had continued, and one child had died.
Dr. KoREitCKs said that any woman with Bright')) disease in
any form might b«coin<^ pregnant, uud that when she did ho she
ran tlio risks of rooal diseaae hcsidea those of preguacicy. She
might have eclamp*ia, and without eclnmpiia ihe might have
dropsy, retinal and other vascular changes, and coma. He gave
details of two caseo of Dr. Galabin'a, iu one uf which the patient
had retinal changes aud optic neuritis, and in another suppres-
siou of urine and coma. Both died, and at the pOHl-uiortem
examination the kidneys were found to be respectively of the
large «bite and small granular types. In neither instance waa
there any fit. He asked w hether any difterenccs in regnrd to the
auaotity and quality of the uri-a and albumen had been found in
JO pruetnt Bcrtoe of caecs, eoni|iurcd wilh the fornuT scries, to
'Warrant any concluHiou as to the caudal relationship to fits. lie
thought that tbe nervous eystem played an important part in
tins production of tilD, and iu the prcM^nt aenen only one patient
was Niugle, aud at she was n ttocuudipura it could be iutagiued
that she was not so purturlu'd mentally as shu would huvu been
had it been her first prtgnaucy. In tbe other three cases there
waa no mention made of mental shock.
Mr. Albj,x DouA^r ubaerved that there appeared (o bv three
VOL. XXXll. '^b
PRKdNAKCT WITH DKIGHt's 1I1BEARE.
diaensofl clinically ttistiuct : (1) nlbumiuum associaicil witb
ovariiiu aui) oilier alxlominul tumours, (a) tlie albuminuria of
pregnaacy, and (3) true Bright'a discaae coniplwfttiog abdo-
niinal tumour or pregnancy. Of tie first, he liiwl seen doaena
of eases. The urine was uaually of high epecific gravity, and
th« amount of albumen oousiderable, always disappeariog after
eucceBsJ'ul reniovali of tbe tumour. EdHiupsia nnTer oCcuiTfid ;
uever ia the annals of tbe Samaritan Iloapita! bad any case
of the kind be«n recorded where fitu took place wlien the
tumour grew very large, or after a big tumour or many gnlloas
of fluid had beeu removed, Tlie second form wna oltcsn anao-
ciatcd with eolampsia. Tbe third form of necessity pxiKt«d in
some casetF, eince Bright's disease was so commuD. Mr. l>onu
bad for many years watched a rase of this kind. The patient
was all tbu better for ovariotomy, which be performed in Decem-
ber. 1SSj3, and, though wenlt, remained, wlieu lail awn, several
yearii afterwards, free from any eign of nephritia. He bad
observed siitiilar cases in tbe wards of bin colleagues. Patients
Hubjeet to Bright's disease during pregnancy wore usually all tho
better for delirery. Tet the general eurgcon dreaded operatioiu
unoii persona eubject to Bright's diseaae, and not without rcaaoD.
Mr. Uoran veutured an eiplauatinn of this curiouB fact. After
amputation of n limb, or ligature of a large artery, a patient with
Bright's disease was, for tbe time, all tbe wor«* fortbc operation,
aud therefore in greater danger than before. The ojMjratioD did
not inButnce the kidiieya in any favourable mrtnner, and pro-
bably forced more vrork tipun those diecaflftd organs. Alter the
taking away of a bulky tumour, or tbe birtb of a fottus, the
patient was all tha better, since a very grave complication,
directly influencing the dieeaaeil kidneys was removed.
Dr. GRiFHTn stated that this was especially a Biibjeet in
which obstetricians needed the help of pbysicianf, particularly of
those who made a special etudy ofkidney-dieeBses. There were
few subjects, except perhaps iililegmasia dolene, needing more
information as to their natural course, and Dr. Herman's con-
tributtona were amongst the ino^t valuable. He criticiiud tho
luc uf tbe term Bright's dini^ase, be^'auav our knowledge of the
dtsease of the kidney was too uDHuliftfactory, aud be thought an
indefinite term, aucb as the "reual aSection " of pregnancy and
parturition was free from anch objections, Colinheiai's lectures
on pathology, now in progrosn of translation and publication by
tbe Sydenham Society, were valuable in relation to this subject.
Dr. Hebman said that eomc of tbe questions asked, although
interesting and important, were outside the ncope of bis paper.
He bad made no attempt to draw general concluiions as to tho
courae of neplmtis in pregnancy ; as to tho frcnuoncy with which
renal disease in prugu&ucy persiRted after delivery ; as to the
cauBo of eclampBJu, or the relutiou between Brigbt's disease and
rBBONANCY WITH BRIQHT 8 DI5BA8K.
85b
cvlampain. Oae speaker hud aeked oe to wlmi nav mcaut b;
" Bnf;ht.'e diseaae." Au tminent Hueceseor of Dr. Bright bad
said that we ought to speak of "Bright's diseases" rather than
"Briglit'a dieeaae," and be (Ur. Herman) had used tiie term
ID the (^oniprebvDBive eenee thus indicated. Mniiy nblc writers
DD obstetrics regurded eclampsia ns oothiiig ehe that: iirwmi<;
canvulBiotia opcurring as the reeult of kidntj'-diseoee io preg-
nane}' and childbed. There waa very little evideni;e eitlicr tor or
againMb this view, which was m&iuly based on inferences drawn
from our knowledge of reniil disease apart from prL^gnaney.
TbiB Bi-rica oE cnees, and otbtre publisbtrd in furm^r papers, wi-ra
an attempt to supply some data tor the aolittion of itis problem.
TheEe data were at present too few to permit general cunclueioaa
to bo drawn from them. He did not think that in Cfisee such &a
those which he had reported, the albuitiiiiiiria wan naimpk result
of prusBure. Tho characters of the kiduoy which were the result
of reooua congestion, and the kind of urine «ocretod by snch
kidnejra were well known, and llie urinewaa ouite ditTerent from
that of the cases now reported. He had not discUBsed the treat-
ment in the paper, but, as might be gathered from the mode in
wliieh hia caseo had been treated, he agreed with Dr. Hayes tlmt
induction of labour was the best course. He had made uo inves-
tigations into acetouuria in pregnauey. In a former paper, jnib-
lishvd in vol. xxix of the ' Trausactioue,' he had cullei:led all the
observiitions thnt he cuuld Bud recorded ou the uormul urcu
excretion during pregnancy and lying-in, and the raBults wero
ao coutradititory that it could not Se eaid Ibat we had any
definite knowledge about tt.
3&6
ON PLUGGTNa THE UTKRUS IN SEVBHB CASES
OF POST-PART0M HEMORRHAGE, WITH
NOTES OP A SUCCESSFUL CASE *
By Arthok H. N. Lbwbbs, M.D.Lontl., M.R.CP.Lond.
tlSIsrAMt OBStHIKtO FUTSICIkK TO TUB LOHllOIt HWflTAL.
(Boocived l^'ebniuy lit, 18D0.)
Dii. Auvakd's ' Travanx d'Obst^trique,' piiblislied last
year, contain an important luoungraph on " Tainpynne-
meiit Intra-Uterin." He reviews Lbe liiatoiy of tbia
treatment — plugging tLe utema for poat-partum. beeujor-
rbaj,'e — wbicb tid recently had fallen into diftWC, and
assigns t)ie credit of introducing it to Leroux. Dc.
Auvard quotes a passago from an account of a caso of
post-partutn biBmorrbiigG published in Lgpokx'h work,
■' Obserratioii sar les pertes de sang" (177ll) in support
of this view. The quotation is a.» follows: '' The tampon
introduced into the vh^iuh came out tbe next day, while
the patient was paBsing- water ; that tchtch wan in the
womb waa only expelled on the fifth day — it was aoeked
with a puriform fluid."
Dr. Auvard gives details o£ seventeen recent cases in
which plugging of the uterus for post-partum haiaior'
rhage was adopted ; nine of theee weve by DiihrssoDj two
by Fraipout, one by Secheyroa, and five were by Auvard
himself.
Three of the &eventeen caseB diodj bnt Dr. Auvard
does not think that auy oue of the deaths can be aticribed
to the breatmetii ; for one died of eclampsia, one oF taber-
* Tlie itbovii licnding does not nccnnitcl; represent the scope ortlui p*p«r,
«uil nliould bitrobccD u foElttws; — "On ii C«bii iu wliicli the Utcrn* iru
plnggtfA for HwiiiorrliaKti nfl«r MifearriHge >t th« fourth montli. with
Itvmaikt oil plugging Ihv UUmt tor I'oit-partuiii Unmonrtiagc " (Authur).
OTKftOS PLDGQBD FOR H JIHORRHAOK.
367
cnloeis (two months after delivery), and ouly one died of
septicrouiia ; iti this case, toOj immGdiate perineorrhapliy
had been performed.
I read Dr. Aavard's monograph last summer (1889)j
and the retitilts given seemed to me so enconraging tliat
' I determined to try the treatment in questiun if I should
meet with any case of posfc-p»rtum hfemorrhage where the
QBual methods fniled to stop the bleeding.
Followiag Dr. Auvftrd'a classification to some extent,
eases of post-pnrtum Liemorrhnge may be conveniently
divided into two classes :
1. Cnacs whore the hiemorrlitigo is moderate.
2. Cases where the htemorrhtige is alarming.
1. )Vhere Ike hiemorrhage h inodvrate, its cftuse may
be slight uterine inertia or some trrHing wound of the
vulva, vagina, or cervix. Apiirt from the use of pressure-
forceps or ligatures to bleeding points that may be
* aooesBible, caaes in this category are usually successfully
treated by —
Manipal&tion of the uterus through the abdominal wall.
The use of hU aiitieeptic injections to the vagina or
uterns, and
The administration of ergot.
2. In tho other group of capes, i. e. where the hnsmoT'
rhage %» alarming, it may be due to —
Great aterine inertia, or
Some cxtumnvc laceration of the uterus.
In addition to the means already mentioned for con-
trolling the hffimorrhage, there is —
The introduction of the hand into the uterus, and if
that also fail, the only alternative hitherto generally recog-
oiaed has been the apph'cation of perchloridc of iron to
the endometrium ; now, however, wo have what appears
lo be not only a safer, bat a more certain method of
treatment, viz., plugging the cavity of th9 uterus and
vugina wilk sonje irieh maleriat £U iodoform-gauxe.
The Dotes of the ca»e in which I adopted this treatment
are as follows : — Mrs. M — , a lady about 25 years of age,
358
VrSBUS rtUaOKD fob nXMOURDAOB
Itacl a tniscarriag'e ou tlie ercning of October 17th, 1889,
wLou about four tuoiitha pregnant.
Sbo was an extremely nervous woman, and her medical
attendant was almost certain that all the placenta had not
come away, but she was bo difficult to esamiue, tbat no
more was done at tbe time, nad be hoped that the rest of
the placenta would come away spontaneously. However,
the next day there w&s an extremely offensive discbarge,
and in the evenings the patient had a rigor and a high
temperature.
I was asked to see the case on the 19fch October, ubont
thirty-eix hours after the miscarriage, with a view to a
thorough examination being made under an anjesthetic.
Chloroform was given by Dr. Hugh Smith, F.R.C.S.,
Besidonfc Accoucheur at the London Hospital.
On examination the os was patulous, easily admitting
two fingers; there was a putrid mass (subsequently found
to be of the size of a hen's egg) partly protruding through
it, firmly attached at its upper part to the posterior
uterine wall. The patient was then placed in the litho-
tomy position, and the uterus drawn down to the vulva
with a volseila ; as mncb as poflsible of the mass was
then removed with the fingers. The rest was taken away
with strong ovnm-forcepe. So far, uothiug unusual had
occnrred. In order to make sure that the endometrium
had been thorooghly cleared, I then gently scraped the
posterior wall of the uterns with Recamier's curette, an
instrument that has a bliuit edge, and scrapes without
cutting. Some more putrid fragments of elot and pla-
centa were in this way removed. It was at this time
that alarming hiemorrhage suddenly occurred. I imme-
diately irrigated the uterus with some very hot iodine
water, which was at hand ready for washing out tlie
uterus at the end of the operation. This did not check
the hcemorrhage, which waa so copious that I felt eure,
unless it could be quickly stopped, the patient must die.
Accordingly I determined to plug the uterus.
The nntorior lip of the cervix being steadily held with
AFTKIt HlSCARRrAOE.
369
tlie ToUellft, a long strip of dyy carbolic gauze, aliout as
broad us Uie 1iau<l, aud couaistiug of four thickubssea of
tbu material, was carried up to tbe fundus with orum-
forcepn, and blic cavity of the uterns was paolced ag
rapidly as possible, ino»t of the packing being done by
pashiug up BuccG38i7e portions of the gauze with Recamier's
cuvette. The first strip was not nearly long enough ; a
second was therefore knotted to its end.
Iodoform waa freely sprinkled on the gauze as it was
being iueerted.
The early part of the plugging was aomowhat difficalt,
because, owing to the largo quantity of blooil coming
away, the gauze hocanie so slippery that it was diHicult
to avoid bringing it out as the iustruuieut used to push it in
vras each binio withdrawn. As soon as a yard or so Lad
been pasbed in the process became easy.
The uterus and ragina were in this way tightly packed
with carbolic gaiae, spriukEcd with iodoform, and n. T
bandage was put on very tightly t-o prevent the plugs
from coming out-
The bleeding was oompletely stopped, aud the uterus
coold be felt easily in thu hypogastriutn, though at the
time die hromorthage occurred the uterus was so much
rolaxed that ita outline could not be distinguished.
The gftuae wag left in till next day (twenty-one hours),
it waa then removed aud the cavity of tha uterus washed
out with iodinc-walor. Antiseptic vaginal douches were
used for some days longer. The haemorrhage did not
recur, and the patient made a perfectly satisfactory ro-
covery.
Kemarka. — It will be seen that the only instruments
required for plugging the uterus are—
A voliella to hold tbe utenis while the plug is being
pressed in, aud a long jtair of owm'forcejMi to carry tho
gauze np to blic fundus.
Smith's modification of Sima's speculum is aseful, but
not essential, and I found Recamier's curette very conve-
venicnt for packing in the gauze after the Grst portion
860
UTKRD8 PLlJOaRO FOK nA:MORKHiGK
had Ijcen inserted with ovum-forceps. Tlic curette bcmg-
narrower haa less temieuey to pull the gauze out as it is
withdrawn.
Ah regards the viaieriiil iieetJ for plugging. — Dry carbolic
gaua© sprinkled wilh iodcform (in coaree powder} did
very well in my case. Carbolic gauze is A stool-er sub-
RtflTiee than iodoform-gniiKi?, amJ therefore has the advan-
tage that less of it will bt' re(]uii'ed.
It is of oourse highly iinportftnt to have an ample supply
oF whatever material is to be used.
In order to give some precise idea of the qoantity of
o&rbolic gauze required to Bll a given space, I have triod
how much can be jirtsaed into a pint uienaure. The
gauze used was four layers thick, and uvcrugod four inchen
in breadth. It was fouud that thirty-four feet four inches
were easily eontained in tho mt.'nsin'0.
If about to plug the uttTua and vagiua after delivery at
tertn^ I should therefore tika to be provided with not tegs
than four times that quantity — that in to say, about forty-
Bix yardtt.
So far as the data at present before as afford materinl
for an opinion, I thiuk tlint jilugging the litems and vagina
is an effectual treatment for many cas«s of poat-portum
hiemorihage that would otherwise prove fatal.
Dr. PaiESTLEY >aid lie bad listmied with conaiderable Interest
to the reading of the paper, but lie could not hHp voudenng
how eome oftliD obatetrlLNatiK nf a pCLSt gciiirntinn wunld linve
look«<l upon tlic propoxitioD to pluf; in poiit-purtuiii liiDiiiorrhiMfe.
He rather IhoiiHht that Buch mpn na Simpson, KamiibfltljAtii.
Bi^b\, aud Arthur Farre would h^ve looked upon ttie propoBiil
with liorror.au das contrary to all estnblislied principles. He could
nnswur for it Unit, no long time ago, a rnnditlate tJoCore the cou-
joint board who mftintnined that phiggingwaa the b^st treatment
for poHt-partum liicmorrtiage would linve been regarded as an
unHound and unsafe prai^titioner; dqi] if he wan not mislnkeo,
tbie cnndidate would hnve n bad qunrter of an hour at the
table of some of the present i-x*mincrB. The Society was
nlwayn gla^ to henr of new nielbodu of pmctioe in midwifery, and
it wfts well tha.t they nbould come bafore auch a Society as the
Obstetrical, because here the eubject could be well threeiied out,
AFTER UiaCARItlAGB.
361
and t]ie reMOQS for and Agajiist Tally deWeJ. He tbouglil,
liowever, notwilbstaading wliat had been Htated in Dr. Lewers'
paper, and the Rutbority Up hmi (|iiol»d in fiivour of the pro-
ceeding, that t liere were radical objoctionsto it ns n generil tnothod
of trefttmeut which would need more than a series of illuBtrati?e
casesi to remove. And he might aay at once that the case given
by Ur. Levers as Bncce^aful in his own practice was not quite a
case in point. As the patient, be uotierstiiod, wae only Four
montha preguint, the utertis wiis but little lievelop^d, and
plugging even of the vagina might bavo been quite a legitimate
method, because there was no large and eipaneible uterinecavity
above it for the accumulation of blood. (To plug the vagina at
tho ful! time would be to iucur the risk of blood accuuiulating
in the woml] -cavity ; and even If none escaped from the vagina,
the patient might die of the resoltiag syncope.) At the full
term of pregnancy the womb-cavity was so large and so dilatable
immediately after the evacuation of ile ci>uteut», that a very
large amount of material would he required tu pack it eSectively,
and the proceea of packing it, with bk'ediug goiu^ ou the while,
would be no easy matter either to the patient or practitioner.
Some idea might be formed as to the amount of material required
for vtiifRog llie empty uteru», when it was remembered that the
average weight of a child cxpcllpd was 7 IbR., and tho plaeentn
probably from I to 2 lbs. more. But he thought the most
tterious objection wa« that the method suggested directly
oppt)««d, indood abeolutety thwarted, the physio)ogii>al pro-
ccaa provided by nature for eecuring a parturient woman
from losing an undue quantity of blood aft«r delivery. It was
well known that there was a wonderful mechanism of muaculnr
tibrce HO arr&ugcd round tb« open moaths of the passage at the
placental spot, that when the middle wat of the uterus began to
contract on the separation of the alter-birth, these open mouths
were constricted and occluded. Any tampon, therefore, large or
small, in tho uterine eavity would preveut this mechanisru
coming into play ; and if. perchance, it stopped hiemorrliage for
the time, it« removal might be followed by tho last cnpt^ll of
blood, which in the much-eihausted patient bad been said to be
the cause of death. He repeated that, although always glad to
discuss improvements in practice, ho looked upon the trentmeut
of poat-partum hipmorrhage by the tampon as contrary to physio-
logical principle!, and an less worthy of trust than other metnodi*
which were now employed for promoting uterine contraction. So
he trusted that tho euggo^tiou to adopt tho practice iu these daya
when there waa so much desire for any new thing would not
prove misehievouB. In any case he hoped it would not reeeive
the H&nctiou of the Obt<tetrica] Society as a general method of
treatment in puat-partum htemorrhAge.
Dr. Plattaib said that he had no practical experience of the
362
UL'KRUS PLUOOBD FOR BMUORHniOZ
iDetbod of dealing nitti uosl-partum hemorrhage by plugging tbe
Utoriie. It seemed to nJin, however, that ihere were obvious
objectioQe to this propiosa], uulesa very cnutiouBly cfttricil out.
Dr. Priestley had very well expressed what tbeiie were. It was
an oid'GBtablitihed axiom iu midwifery practice that the plug waa
uever applicable so li^uf; as there was any poeeihility of tho
utertis dilating behind it. A neuly emptied ulerua might veiy
well 4-uDtaiu a I'ntal uumuiil uf bluud iT ouly it« luwer Mg-'
meat were Klled witti the plug, itnd mni^h c&re would be rofjuired
to prevent the posoibility of this oi;curronce. Dr. Lewcrs' wa«
obviously Dot a eane of |]OBt-pAi'tiiin hseiniorrbage at all, but one
of miacnrring^ with a rHaineJ (itid putrid placenta. Here diin-
tittioD i>f the uterUB was not poaiibU', uud pluijgiiig might be very
ueeful. The eatne might be said of secondnry puBt-piirtuin
hiBinnrrhage during the puerperium, wlieu involution hadalrwidy
purtially uvcurred. Iu a bud caae of this sort which be bad eeea
Boine weeks ago, lie iiitendtd to try Ibis plan, the hiemorrliage
having outoe on » fortnight aftur delivery. Whilo waiting for
the iodoform-gauze, however, be used liot-wAter douche* into the
uterine cavity, which efteclnally cout rolled tbe ha-morrhoge. He
should consider it do en«j uiatter to pack a large flaccid uterus
imoiedifttely alter delivery. The burden the accoucheur bud to
bear was already BuffiL-ieatly heavy ; it wnuld beconio ititolenible
if be hud to carry about with bim tbe forly-»ix yardii ol anti-
aeptie gauze which Dr. Lewere estimated aa the <iuiiQtity likely
to be required. Dr. Lenera was probably iiware from bis
dotneslic experiences that the average amount of gauee required
fop a liidy's ball-dreas was about twenty ya^s. It was lo be
hoped that medical tituileiits iu a pnuiu would not quote him aa
an authority fi>r poking the ciniivaleut of two and a half ball-
dreaaea into the uterus after delivery. One einss of hemorrhage
seomed to bim well suited for this trcatmeut, end tbat waa the
kind dependent on laceratious of the cervix or vagina. These
had been deecribed by Godchna " bnimorrhagoH with a coiitraeted
iiterue/' and in tb«m the presence of a plug of antiseptic gauze
would probably prove most elBcaciouB.
Dp. CiliMPNHTB said that he agreed witb Dr. Priestley and
Dr. Plnylair that Dr. Lewcra' coae had nothing to do with the
title oi' bitt' paper. The uterus iit four inouthH is iiicapablo of
daugfrouH L'xpnnsion. Uu f^lt sure tboy mmt all bavt? enjoyed
Dr. Pluyfuir's humorous picture of "The Bleeding and the U&1|
Drcea," and be would have lelt inclined n j»rtorj lo agree witb
both tbe former sjieakers if he had not happened to read Dr.
'DiihrsBon's paper in * Volt(rnanti'« .Snrikmluug kliuieehor Tor-
trap* (No. 347, 1H83, 3. 2}S)0). Tbis gives a circumstautial
aniftabulated report of moi'e than sixty cases so treated, giTing
all uaeeBuary details, sueb bh the nmouat of bleeding, Ibe effwc
va tbe patiiiut, Lbs presence of lauc-ratioiiv, and tbe meaaa pre-
AFTER UIBCABBUOE.
363
vionsty tried. He thnught that, if the prcviouB speakers read
that, they would be obliged to coni't-sfl that a new method must
be added to our list, and that it must be accepted aei a Uiit reeurt
instead of tli« daogcroua injection of percrnloriiiie of iron. Tf
{iliigged properly, from, the fundu* dowiiwnrde, the uterua do«8
not expand nbove thu plug, wliich, on tlid coiitrn.rj', actg &s nn
irritnut,and cnuDi^s good eoutraetinu and retrncjtioii Thevftfjiwn
is also lightlj plugged. 01' siitj-Gve cases of severe pOBt-purtuin
litemorrhai^e tlniH treated, six died, one oulj of sepsis. No
" ball-dreas " is required, nor eieii in nnliBe[)ticgauie uoeeasary,
for aDV cleau iiu«u cau be sterilised by boiliug tor live minutes
in ft saucepan or kettle with the lid on, to produce a. uniform
temperature of 212° F. or UK)" C. The (juantity of material
required is lesa tbau would be supposed. Euglishmeii are sup-
posed to live on nu ifilaud, but Dr. Diibreaen stutes in IbHD tliat
the injection of perL'hlonde uf iron is regarded in England as a
practice aa important as raccJnation. This was an instanco of
German insularity, and was at leaat twenty years out of dutOiif
it erer were true.
Dr. Lkitii Nxpisit, in view of what Dr. Cliampneyn had said,
asked ae to the ra^iW^n/t; of plugging the p<«t-partum uterus.
The post-partum was a very differenti organ Irom the post-
abortum uterua. In post-abortutu case* the practice was juati-
Gable, but ttiei-e aocoicd distinct objections to it iu pt>st-partum
conditions. Moat ubstetriciutia held that hxinorrhBge uftcr
delivery waa immediately arrested by uterine contraction, and
that vubeequeui bleedings were preveuted by retractioa, Ue
wished to ask Dr. Chumpneys if he lielicred that an artificial
olotling, uu tho top of a plug of limited siztt as deeeribed, uould
do more than permit temporary plugging ol' the uterine sinuses?
Did normal n-traction occur witli thi« artificial clot inside the
utvrus F Dr. Leitb Nnpier thought it likely that the plug acting
aa an irritnnt would tend to produce coritrnctio]i« in a healthy
uterus ; but, except in those rare caaea in which there was abeo>
lutely no attempt at contraction, dei>cribcrl as uterine paralysia
at the placenta! aite, be fiiiied to see the neee«»ity for or advisa-
bility of the procedure. The idua waa by no means new ; the
treatment bad been suggested long ogo, but never met with
more than very limited adoption.
Dr. Oeiffith did uot look ou this proeeedin;;na iu any seuso
Dew. He had been taught it uhcn n student at the SuHsex
County Hospital in 1873, by a pwctitioner who had studied at
Ouy's Hospilali Plugging the uterus was au invaluable method
for applying the perchloride of iron, nud of courve should only
be used in case* in which ordinary trentmenl fiiiled to ensure
fermaucat retraction uf the uterua and arr«»t of the htemorrbage.
le bad done it in two carRes. Theaei however, occurred before
he understood the advantages of hut- water injcetiou» ; since Ibon
3G4 DTBRCB PLVOOKD FOB R.SMORBHAOE.
he liad bad no necessity for uaiog unytbiag elae. Br. Griffith,
in these cukos, uaed strips of lint (clean linen rogs or di&perB
couLd be uaed in caee« uf em^rgenc?), tk« longer the better, two
to three inches wide and a yard long. Th^se stripe t;ould be
uaed dry, or might be wrung out of a very dilute solution of
perclilorideof iron. The nuree having douesn, ehoiild band them
ncnrly dry to the physii-ian. He then passed them up rapidly
to tho fundus, takm^ special care to leave one end of oach strip
hanging iu the vugiua, eo that they may be eiiaily withdrawn.
\iy thv time n inasa the »\7.e of one or two flMU wus iiiaertcd, tbe
uterus would bv found no firmly eontraotod thiLt it would be
impossible lo insert more. It was quite unnecesaury lo plug the
vagina. Tbe plug should be withdrawn within twenty-four huura.
Dr. Griffith had taught this at St. Bartholoinow'a for eight years,
but it would rarely be found neceaaary.
[Dr. LswsBa, who was not prenent when his paper waa read
anddiMCUBsed, wished to explain that It waa only in those desperate
i"a»ett of post-partum hicmorrhage for which the intra-uterlue
injectiou of perchioride of irou hud hitberto been recumtnonded
that he would ndviae plugging of the ul erine cavity. He regarded
it only as a last rcBOuree when all the usual means failed to atoji
the bleeding. Gernrnn and Prcncli statistics seemed to ahow
that pluggiug in ouch canes wae much lesK dangerous than tho
iritrn-uterine injection of perchloride of irou, and at least equally
cirK'ttoioiie.]
DECEMBER 8rd, 1890.
Alfred L. Galabin, M.D., President, ia the Chair.
Preseat — 41 Fellows and 5 Visitors.
Books wore presentecl by Dr. Bmxton Hicks, Dr. Leith
Napier, the Clinical Society of Londou, tiud thf Mcdicul
aad Chirnrgicul Faculty of the State of Maryland.
A. W. Mayo Robson, F.R.C.S. (Leeds), wan duclarud
admibtud a^i u Fellow of the Society.
TLo foUowiog geutlemeu were elected FcIIowh ;-^
ThuniAS S. Allan, L.K.C.P. and S.Ed. (Tonbridge) ;
Skene Keitli, M.B., C.M.Ediri. ; Edgar Asbloy Lubbock,
L.H.C.P.Loud.; John RejTioIds, M.D.Brux.; n.ud l-'rodt-rick
Sloman, M.R.C.S. (Bnghton).
The following gentlemen were proposed for election ;—
Ernest Dawson, L.B.C.P.Lond. ; W. E. Picton Phillips,
M.lt.C.S. ; and Frederick William Kanndera, M.H.,
B.C.Cautab.
THE BEGISTKATION OF MIDWIVES.
Thb PicESiDKNT said thai, some qucstioua Laving been
Mkod about thu uctiou of Coancit in regard to the pro-
posed Bill for the Registration of Midwivcs, tbo Council
desired him to etate the present position of that matter.
TI8ICAL CAf^ULUB.
During the summer the Conncil was asked its advico
in reference to the provisions of the bill then in charge of
Mr. Pease. The Council considered the hill, and BUg-
gCBttd a nuuibor of amendments in it, many oE which were
accepted by the committeo in charge of the bill.
Since then the bill had again been greatly tranaformed,
and tho Council had not yet considered the details of the
bill a<3 now propuned. A special meeting woald be held
this mouth lor the purpose. Meauwhilo tho Council bad
deferred the question of referring the Bobject to tho
Society at large.
POLYPOID IfTOMA OF THE UTERUS.
By A. E. AusT Lawkenck, M.D.
Dr. Ausr Lawbence exhibited a large myoma of the
uterus which had become polypoid and lay in the vagina,
compltitely blocking the pelvie, and resting on tho
pi^riuffium.
VESICAL CALCULI.
By A. K. A08T LiwasNCK, M.D.
De. Ackt Lawrence oihibited Bevorai calculi which had
been remcived by raginal cystotomy, lu & caae of old-
stantliug pi'olapKe vt the uterus and bluddur.
CAST OF A LAllGK VESICAL CALCULUS.
By A. E. ArsT Lawbkscb, M.D.
DiL. Au8T Lawkenck exhibited a cast of a culculus
having as its nucleus a hair-pin. This calculus com-
CALODLI KKOJI A CAbB OP PBOI.APBB OF UTEBUS, BTC. 367
plotcly (illcfl the bindder, and extended along two-tLirds
of tho urotlira.. It was removed by crusliiug through tho
uruLhra.
CALCaLI FROM A CAKE OF PROLAPSK OP
THE IJTEKUS AND BLADDEK.
By Pkecy BoLiTON, M.D.
P. E. H— ^ aged 42, was sent into tho Samaritan Free
Hospital OD July 12th, IS90, with complete prolapse of
the uterus and pelvic viscera. The displaced parts furmed
a tumour as large as a cocoa-nut, protnidiug between her
thighs. This condition was of eight years' duration.
On tAking hold of the mass lu frout it felt like a bag
of marbles, nnd it was evident that the bladder contained
a auinber of calculi. The bladder had not bcea emptied
for eight years, but the urine had ovorHowed from the
urethra, which, now that the organ was prolapsed, lay
appermost.
On July 14th Dr. Percy Bonlton replaced the viscera,
and then dilated the urethra with Hegar's dilators, the
patient being under chloroform.
He removed twenty calculi, of which five were of the
Bir^ of a walnut and fifteen tfau size of beans. (Three calculi
were exhibited.) Two hundred and nineteen more stonee,
□ot unlike split peas, were either washed out of the bladder
or passed in tho nrinc and counted by the nursoa.
Tho bladder was douched with boracic lotion and tho
parte kept up with a Zwancb'a pessary. Tho next day
the patient paSHcd twenty-two ounces of urine uaturally^
and from that time continued to do 80. The urine was of
course alkaline, and contained onc>tcnth of albumen.
The patient returned home quite well.
868
FCKTU8, THE
SUBJECT OF
VESICALIS.
ATRESIA ANI
By W. K. Dakih, M.D., B.S.
This specimen was aii eight montLa' ftctas, born in au
attitude of extrcuit' njt.ro flexion of the head aud truuk,
but with Iho legs flcjtod on tie abdomen, which was
hugoly distended. It was born of the same paivnta as
tbo t'uituB with rctrotloxioQ and ectopia viecerum desct'ibmi
at p. 200 of the pTesent volume.
Lahour. — The preaeiitation was sihdominBl, and the cord
Imd prolapsed. Dealh had oecurred Home da_va before
birth, and the head was very soft and compressible. The
preseutation was nn douht due to thesize aud inoumprcBsi-
bilitj of the ahdumeu, of which the circumference at the
unTel was fifteen inches, and the auterO'postcrior diameter
seven and a half iuchea. On the other baud, the dia-
meter which engaged, namely that lying between tho
front of the neck and the tubera ischii, was not more than
BIX and a half inches, and could bo very easily compreseed
into four aud a half iiicheB or Iohs, the reduction being
produced by yielding of the spine in the direction of retro-
flexion (Fig. 1). Tho cord, a yard long, was wound
8e?eral times rouud the neck. Tho placenta was normal,
aud there waa no trace of another fuetuii.
AUitudif- vf child and ejitcniat iliifurvtitwif. — After birth,
the child reuiaiiiod in the attitude in which it was born,
and in which it had evidently existed for a cnnsiderablo
tinao, as the skin of the hack wa6 put on the stretch if the
poBtnro was altered.
There was a spina bifida arieing from a myelocele in the
sacro-lumbar region, aud talipot varuK and ovcrsion of tho
knees. The lugs «ud feet were cluKoly applied to the
roiTlifl, THK aTTBJrCT OF ATHKSIA ASI VSSICALI*.
ftbdomen, and their deformity wan probably cansetl by
compression between the abdomen and the uterine wall.
.^,
^!
PiQ. I,— Showing nUdoiniiinl protubfrnucr, clrrorni!tiM of legs ttnil
rwt, and ■iiiuu blllilii. (Tbe fatal i* in the mttitnde iiiA;ntnIn(>(t
diiricK Ifthanr.}
Alimentary and genitn-vrinary ^t/gtema. — There was
comploto fissure of the palate, but no abtiormality iu the
pfaai^nx or other part of the alimenUry canal down to
the end of the large iDtestioe ; this wns fouud tu open into
the bauk of a liirge cyst, an will be described. There was
no annSj nor oven a dimple repre»enling it.
On opening the nbdomea, tbc disteDsion was seen (o be
VOL. XXXII. 2*i
370 PinTDS, THl anWBCT OF ATBIRIA AKI TRSICALrS.
cnnsed by the large cyst nbove noted. This measured six
nnd a half inulies frum back to front, four inches from
/'A
~3
Pio. 2.— Cytt turnod d«wiv, uliowing (a) lar^g Siitwtinc, openinit
at fr- c. TiMticlHi. «'. Leftviu Oi^fcretm. if. Vmbllicnl vris. «.
Right iimbilioiil urtory. /. Itigtil (pi'Tiaiitic nrtvr^. y, Kiiln«T
witli nreUr.
abore downwards, and tlireo iucliea ncrosB. It was en-
tirely above the brim of the pelvis, and reached Jronj the
front of the lumbar spine to the umbilicus, being attached
Do the latter by a very short Htraiid of tissue (one quarter
of an inch long), evidently the urachns. Closely applied
to and running along each side of the cyst was an um-
bilical artery ; the right was much larger than the left.
The testiclefi were very small, at first glance they were
taken for mesenteric glands. They lay on the upper and
postero -lateral part of the cyst, one on each sidt;. Their
ducts were scon to converge and enter its wall about half-
way down.
MfrUB, THS BPWBCT OT ATRESIA AM! TBSECAMa. 371
On opentug tlie cjsfc about fwur ounces of iirino, with
flakes o£ mecoiiiuin floating' in it, eacaped. There were
four orifices on tho inoer surface ; three on the posterior
wrII (Fig. 3), and one over the pelvic inlet, Tha last led
L.VMfTIn
> 8» t
^y_
Fl«. 3.— Cytt opciieiH. ulioiriiifr praitittlc carity, orlAce* of InFt
ureter and of fful, ami [JOHiituii of urEtlirnl orilti'e (intrnial].
Urttbnt li •ccn lending fruui bladder lo (iciiia.
into a very long urethra,, diucIi stretclied by the elevation
of the eyat. It wiis evident uow that the cyst consisted
of bladder plvs tho oppor p&rt of the utlantois, wbicli
xhould have hecnme urachus, and tho prontatic urethra
which yraa expauded to form the posterior and lower pfirt
of the cavity.
The urethra admitted a brifltle for a very Bhort distance
from both tlio vesical and poiiila end. It wns one^and-a-
quarter iiichoa long from tho oy»t to tho pubos, and in the
iniddlb oE its course was almost but not quite impervious.
The other three orifices were clone together ; one waa
a nlit leading into a blind sac, which probably rcprcBCuted.
kbe prostatic veMcle, as the fteminal ducts ended cue on
372 fVrVij TUB SCBJRCT or ATBKSIA ami VSSICALia.
ertcli side of it. Tho sac wus largo enough to contaiD n
»ma11 pwi, its mucous mombraue was redder and roiiglier
tlmu tbat of the rest ui the uyst, and a tract oE very thick
vrliite mucous meinbi'aiie about half an inch wide and two
inches long extended fnnn it to the opening of tho aretbra,
and was the prostatic mticous membrane spread nut.
There was no prostnte gland.
The two orificfs remaining were those of the intestine
and tlie left ureter. Of the two the former was the
emaller, and either readity itdmitted a Ko. J catheter.
There was no right kidney or ureter, and the left
kidney was hydi-onephrotic, with, however, an undilated
ureter.
Both adi-eual bodies were present.
All organs of the body here imnientioned were normaL
Mcth<il of prodnrtion of nbnurmalify. — Together with
failure to develop a cloaoiil orifice (which should occur
normally about the fifth week) the lumen of the gut had
remained coutinnous with tie cavity of the allaatoia, and
the contents of the bowel were evacuated into this cavity.
The urethra must have been incompletely developed, and
the outflow of urine interfered with to some extent, bo
the cyst became distended, rising out of the pelvis and
stretching the urethra (membranous portion) till it was
nearly occluded. The backward pressure would then act
on the kidneys, and caused in tbia case hydronephrosiaof
one and dieappearance of the other.
Spina bifida is of Common occurrence in combination
with malformation of the alimentary tract, for rousonn
now pretty universally accepted.
The cause of the talipes has been mentioned.
The retroflexion was entirely due to the pressure of the
cyst, and disappeared on \U evaeualiou,
Previi>7ig occtirrmite in/amUif of an allied form of winn-
gtroeitf/. — All interesling feature of tho case wm that the
f<Btiis WHS born oE the same parents n.t another, the subject
oF retroflexion of the spine, ectopia viscerum, &c., shown in
itH fresh condition by the writer in November of last year.
rcETVS, THE SDBJBOT OF ATBIBU ANI TE8ICALI8. 373
Fxes. 4 and 4i. — Jiod« qforigiit qf f^normiUitj/.
¥ta. i. — Praviona to formation of primiUve cloacal opening j allan-
tois atUcbed to anterior wall of gut with a continaona carity.
0. t. Ovary or testis. «. h. 4* d. Wolffian ttody aud dnct. ur.
Ureter, all, Allanttua. oL Ont.
ii,a.
Fio. 4a. — Parts M developud in proent ipecimen. «. a. Umbilical
arterj. g. Ont. t. Teatii. k. Kidney.
S74
6AB00HA or THE ITTBBDS.
Wld tjubscqiicuily diBsocted and described in tho prcsoot
voluiuu ()). 200). Ill tliis case ako all the abuormalittos
could he tniced tu u t'ailuro iu dcvelopmonl of tho hiud
gut and it.3 processes (see pp. 212 — 214).
J>r. HonitoCKii mentioned a cane iu uincli them wna atr««is
of rectum, vagiua, and uretbra in a female child. Tlio bladder,
utcru», aud bowrl formed Ihroo di^ttended CAvitiea cBuaini; so
much dyntoi^ia ufCer the delivery of the bend ibat the uterus rup-
tured and the patient died. The fcetue waa dissected curefullyi
by Mr. Turgett, and waa now in the museum at Ouj'e Uoapital.
PAPILLOMATOUS OVARIAN CYSTS KKMOVED
DUKING THK FOURTH MONTH OF PREG-
NANCY.
By W. A. Mkbkdith, M.B., CM.
SAUCOM^V OF THE UTEHUS REMOVED BY
VAGINAL HYSTERECTOMY.
By W. J. Gow, M.D.
Till; patient was a womac, aged 49. Showas admitted
into the Metropolitan Free Hospital compiaioing of uterine
ho3moiThngG. A soft, friflhlp, peduncnlatod maee, aa big as
a largo orange, was found projootiug into the upper part of
tho vagina. Its stalk truuld be traced up through the in-
ternal OB. This mass was removed with aii ecraseur. A
few weeks later the entire uterus was removed through the
vagina. The broad ligamenta were secured with silk
ligatures. The patient made an excellent recovei-y. The
growth, which praved (o be u Ijuipho-sarcoma, originated
ia tho wait ^f tho uterine cavity ulose to thuoriHce o£ the
left Jallepiau tube.
37o
RUPTURED UTERUS OCCURRING DURING
LABOUR AND AFTER EXTERNAL VIOLENCE.
By John Phillipsj, M.D.
Thk pntient, aged S7, was tlio moblier of fcen children,
aud bad bad no mincaTTingas; alt her previous laltotirs liad
been quite normal and easy, tbe vertex preseutiog in
©very case.
Ou the evening of Jtily llth, 1890, her labour being
uearly due. Hie was violently kicked in the right groin by
her husband, who was intoxicated and was wearing nt thu
tiaie heavy bob-nailed boots. She became sick and
5unt, aud was in couslderablu pain during the whole night.
Twelve hours after the uHsault her labour came on ;
everything progree&ed well until y p.m., when she com.
plained of considerable tearing pain in the lower abdomen
accompanied by a sen&ation of fuintneas. Soon afterwurda
the paiuft became k-gs frequc-ut ; tlio presenting breeeb nut
advancing, and tbo abdominal pain being constant, I was
asked to 80© her. 1 found an extensive purple bruise in
tbe right groin j the patient was in a eold BWeal, her
face Bslieu coloured, with a nmnll but regular pulse uf
130 per minute. Tbe breech was presenting niid lying
on the perineum. Tbe pains occurred at intervale ; they
wore very feeble in character, and appeared to have no
effect on the advance uF tbe presenting part.
1 delivered aa rapidly a« possible by passing a silk
handkerchief ovcT the right thigh by meous of n cupper
wire. Extraction waa quite caay. On pa«l^ing my band
into tbe vagina, I found a nearly transverse rent anteriorly
in tbe genital c&nal. Several loops of intestine could be
distinctly made out.
I expressed the placenta, and after injecting the patient
with etber eubcutaueuuslyj went away to procure assiftl-
376
ItUll'UIUiD Ul'KKUS.
ance anil iTie nece&sary instrumeDts Eor lApBrotomy, Onj
my rotiiru, liowc7er, she was pulseleee and uioi-ibuudi auc
died sLortly a.fterwarda.
Pvet-mortvut. — The abdooien wa8 enormously distondud j
there wns weH-tuarked emphysema of the abdouiinftl wall
and 8ubp&ritoueHl tiesuee. More tliau two quarts of
blood in a fluid state with clot were remuvod fryin the
posterior cul-do-sac. The blaJder was uninjured.
TL(! uturuH after removal showed an obliqne tear four
ttutl a half inches loug anteriorly and to the right, tbrongb
the lower &Bgineut ; the rupture through the tissues
was complete. The uterine tissue elsewhere was qaibe
healthy.
It WHS coucladed that the kick had lacerated eome of
the uterine fibres, and that complete rupturo cneDod with
labour.
Dr. Phillips had exhibited this spoeimeu for throe
reason B : (1) Tlia rarity of rupture at this &ite. (2) The
uiiii»uul causo oF the rujitute, (tiiuilar somewhat to the
lo-called " catt]t;-horn " ruptuivs. (3j The questioDg
arising medic«<tegnlly from such a. case.
377
NOTE ON THK OPERATION FOE RESTOUING
THE PERINKAr. HODY IN COMPLETE KUP-
TUHE 01'' THE FEMALE PERINEUM.
By A. E. Au8T LiWKBWcK, M.D.
(UecoWed Marrli BOth, 1890.)
Uaviko Operated on thirty caaes of complete rupturu
of the female perineum I &m induced to briog before this
Society what I consider to both^cliief puinta wliich must
be nttcndoU to in order to ubtaiu sutcess.
Twonty-oigbl of ray cases sueceodcd perfectly at tbo
6r«t oporntion. The other two wer^ successful after the
Becond opi>ration. All the cn^cs nnffered fi'om incontinouco
of ftBoes and innbility to roatrain flatus, the niptiiro iu
all being ooraplotoly through the lower portion of tho
rectum. Is all the operatiuu was au absolute ueco8i«ity.
Now the secret of snccestt in repikiriug this iujury consiHtit
in freeing the rectum from its altHchmeiitK in its abnormal
ttituiklion, and in bringing it down and fixing it in its
proper place.
The operation I perform is that known as ^plittiii^ thu
septum, for the £rat idea of which I was indebted to Mr.
Laweon Tait.
M. H — at her first confinement hud the perineum
ruptured through iuto the rectum, with the result of incon-
tinence of fracGH, &c. A local surgeon tried to reslurB the
periDenm, and failed after two operations.
When I saw the wonian she had a large hole through
which I could paxs my finger between the rectum and
vagina, and the parliiilly restored perineuui had alao two
large boles in it.
378 oritKArtoN for BBSTOBiva the fbbineal soor
I stit tbe remaining tissues up, and on passing my finger
deep down iu the wound I felt some wire Boturea whiolt
bud been tbere some uoutlis. As oue step of tbe ope-
ration I picked awuy with forceps aud scissors until I hi
removed ail these wire sutures, and then I found I badi
80 freed the rectum (that is to a&y, the anterior porlioD of
it) that I was L'uabled to draw it down level witli the
Kkin, and I further found that thei-o was no traction on
the bowel^ and that alt I Iiad to do was to pnll the lower
end of the bowel down and back, aud n^-n up the perineal
wound in front of it. Tbe result whs perfect imion aud
complete restoration of tbe periaenm.
The BtepB I tafets in this operiitioii are us follows ; I
operate, as a rule, three days after a menstrual period
has ceased. I have the bowels made to act welleachday
for one week prior to the operation. On the day of the
operation there is no action Bolicited. For one day
before the operation and for ten days after, only liquid
uourisliment is given. Tbe patient iu of course kept tn
bed. No opium is giveu. The catheter is used every
eight hourB. One week after the operation the bowels
are relieved by giving small and repeated doses of cou-
fcctiou of senna and tiiilpbur, and thenceforward a daily
BUition is obtatued. The »utui-es arc removed on tbo tenth
to fourteenth day, when the wound is found to he perfectly
bcnietl and the patient has regained control of the
rectum.
The operation itself is done as follows: I run the blade ol
a Rne pair of BcitiHcirs along the Kharp edge oF the cicatrix
in the recto-vaginal septum, and at each end of this
wound I carry tbo incision about one inch forward into
tbo labium. This Hap is now pulled forwards by two
pairs of Wells's forceps, aud sufficiently freed by a few
snips of the Nciasors ; thin now gives a certain amoant of
raw surface, The important part of the operation is now
to be done. I take hold of that portion of the svptum
left, after what may be termed the vagiaal portion has
bsGu carried forward. 1 rcgiird this portion as fumisliiae
IW OOUrLBTB fdfTORl
iiNKUK. 379
a new rectum. 1 take hold of it iu tivo plaCuH with
Wells's forceps, and make a clean cut with scissors on
each side backwards for oboiit half nn inch, and then
enip away iu jfront and to the sides, until I enu bring
■down a complete tube to the level of the skin of tbe
periucuiu. When this i*i doiiu I dimply Imvu thi» new
rectum hold back and sew up the wound iii front ; by so
doing tlie perineal body is formed with the rectum onco
more in its Bormal position. I use pure carljol ised silk for
sutures, and bury most of tbeni completely iu the wound.
In introducing the suture I do not include the skin, I
urn sure there is less pain when tbe skin is uot iacludod
in tbe sutures. Also if any swelling; taUfs place iu tho
■new perineal body, the sutures can sink in a little on the
ivi'G uui-face and ho tako ofl the tension of the deeper
parte. Before commencing the operation I pass a piece
of sponge up tho rtJCtnm and another piece up the vagina ;
these of course are removed after the operation i» finished.
Tbe after- tTeatment is, as I have already mentioned,
exceedingly Bimple.
There arc ooine caseB where it is impossible to bring
down u complete tube, owing to great lose of tissue ; then
I bring tbe rectal portion down as a tube incomplete in
front, torn in tbe raw surfaces, while they are still held
by forceps, and pasa my perineal satnres through these
flaps. Thus tho tube is completed. I am sure tho real
secret of eucco&s lies in completing the rectum, and Hxiug
it as an entire tube behind tho new porinoal body. The
auuK in all my eases, directly the operation is finished,
bulgcK tiut HH if afflicted with hninorrhoidN, and if a million
took place immediately, nothing could possibly enter the
perineal body.
860
TGK PDHHE-STRING SUTURK : ITS USE IN COU-
PLETE RUPTURE OF THE PERINEUM.
By I'SKCY BouLTON, M.D., M.R.C.P.LoKb.,
BUXBtCIJUr to TBS SUtABlTAM rBKB UOsnTAtu
(Recdv-ed April 11th, ISM.)
{Ahftracl.)
The pApvr dva<;ribee an opeiutioii whicb the author buM «ui*
[iIovlkI sutiL'L'Hftfully in aevuuty-lhruB oasuu of L'oinpk'te rupture
of till! pi!riucuii]. The method of nuiug the piirsc-striii}^ vutui^
is expliiiaed. and it is vUimRti that by menus of it the Hphiucter
ojii is more perfectly reetorcd than by other methods of opera-
ting.
A serieB of diu^rama auuomjiany the paper. The so-called
" itei'iimi! body " is formed by the clastic tiseuti which uonstitutea
tbe at tac bine tits of the posterior part of the sp]]iiict«r VAg'inae,
tog-jtber witli that of the two transverstLkfl jtcrinci diuscIch aud
tbu anterior attachment of th« 8))hiai;ter ^ui.
The loss of thflsc attachmenta by complete rupture is shown
iu Fig. 1.
The posterior va^ual wall bus shortened bo &» to form a tliick
tungue at y, while the sphiQcU-r luii ti.nd trunsv(.'r»Rk-s [loriiiei
haye retracted behind the rectum, and the 3pbiti«ter is seen
thiTO iu nearly a stntigbl line forming niimei'OUH rugw.
Fig. 2 repreayuta the liimB o£ inciHion neeeaaary for repair.
The touKuc If is diBBeckd up to a c. The audit of tin.' iipbbcter
are laid bare at jtb aud a o, and the points \a aud ci> arc
oouuected by iuciHioui. The tiuBUi^s botwcini these letters arc
dt'ntided.
Fig. 3 sliows tliu reolul tear (v is ct. No. 2) closed by two gut •
THI POaBE-STBtNa SUTrGE.
381
sutures tiL'3 in the bowel, Tbt; Ji»ursL-. string suture ift seen
[Misaeil tbrougb tlie emls ot tbe ex|Ki8i;<I aplikiotLir uiii and ap
the recto-vwgina-I wall as far aa th« ba.ee of the tongue T.
Pig. 4. — The purse stniig iit tiod, «liowiiig tho cirole of the
sphincter perf<>ctl;i' restored, and the three sutures arc in |ilftco
for cloalng the perineum.
Bo many operations for the repair of the female p^ri-
neam have been described tliat some miglit helieve that
nothing uew romaiiic-d to bt- anid on the subject. Great
improveuieuts have, however, token place withio the last
thirty years.
lu the days of quili-autoree, slouffhing of the tissues
and failures followed long operations of a,n Lour or more,
and the period of oonvalesoence frequently extended
over a month.
An opdinarj perineorrhaphy can now be completed in
ten minutes ; tbe cures shLiuld be lOO per uont., and the
pnlient need not be coufiiifd to her bed for more than ten
days. Nothing can be more certain or more perfect than
tliis, and it is only when we come to complete rupture,
the tear extending through the sphincter aui into the
bowel, that there is still room Cor discussing the methuds
of operation.
I bolievo that many experienced operators not infre-
qaontly fnil to reetore the power of the sphincter ani so
that it will hold liquid foices and flatus, the reason being
that without Nuch a lever as the purse-Ktring KUture it is
difficult to raise the endx of the muscle to the centre of
tbe perineum and keep tliani there so as to complete the
circle of the sphincter, which remains weak in front even
when the recto-vaginal wall ia perfectly restored. Till
1880 this was frequently my own misfortune, and it wan in
that yoartlrat I commenced thu treatment of the sphincter
by the " purse-string " suture.
The operation a« practised by mewaa described by Mr.
Albnu Doron in his " fiynnecological Operations," but
verbal descriptions imperfectly convoy tho various steps of
sea
THE PnBBR'STBlNQ atnCRI.
the oppralioii, which is not (liSi(iult or comph'cated, ancl in
the wnrHt ca^ea can be complotrd under thirty minutes.
Up to the end of July, 1889, I had operated seventy-
three times. In no case has it been necessary to repeat
the operation, and in only a few has the result bccu Boy-
thing hut perfect. Id Bomo of the earlier casos I found
the sutures cut from too tight tying, but not 80 as to en-
tirely spoil the result.
Tlie operation, difficult to describe, is easy to demon-
strate, and in the al^sence of a subject I propone to do
this by means of diagrams.
First, it is necessary to bear in mind the anatomy of the
perineeum.
The Bo-called perineal " body " is really nothing but
the iibro-elastic tissue at the fonrchette forming tho
attnobments of —
1, The sphincter iini in front.
2. The two transversalGs perinei muscles.
8. The posterior attachment ot the sphincter vuginse.
4. The longitudinal posterior muscular tibres of the
vagina.
When the perineal body is completely torn through,
the transTeraalis perinei retract and draw with them ths
two enda oE the sphincter ani behind the reotum. Th«i
posterior vaginal wall having lost its attachment shortens
an inch or more and is seen as a tbickenod tongue up the
recto-vaginal wall. This is shown in Fig. 1.
To repair ll)i)t according to my method so as to bring
all the parts again to the central point where they raoac,
it is neceHsary to denude the parts as shown in Figf.
2. The tongue t is spht and dissected up tfl a and c.
The lateral incisions a h, c n must be carried back-
ward far enough to expose the ends of the sphincter ani
between D r, and 0 d.
11 the (more or less) triangular opening into tlio ractam
be large, it should bo closed by two or three gnit sutures,
tied inside the rectum, cut off short and left. If it be not
large the purse-string suture will encircle and close it.
THE PUBBB-STBIira BDTDBI.
383
Fie. 1.
Completfl raptnro.
1. Betneted apUncter.
8. RecUl t6ir.
T. VsgiDHl tongae.
Pie. 8.
Ineiuon* noctMary for mtontion ihown bj lettering >iid thick black lioea.
884
THE PUBSR-BTIIIMQ BOTOBS.
Before stitching tlie rectal tear, the recto-vaginal wall
13 split, the posterior and thicker part heiiig iurued some-
what backward into the bowel when tlio gut sutures are
tied, while the unterior portion lh disaocted off up to tbo
tongoe IT, (Fig. 2), thus compicting the necessary denn-
ilation. The tougiie x is now h«Id ap by inoaos of a pair
of " Wells's" pressure- forceps and the pnrae-string suture
id introduced in the manner shown in Pig. 3. The
gat RutnreM nre seen already tied so as to close the rectal
tear.
The "purse-string" sotare is now paBsed, entering the
end of the sphincter ani at one side, running through the
recto -vaginal wall up to the base of the toug-ue T, which
is auppoaed to be held upward and forward. Uere the
soturc crosses, taking a firm holding at the base of the
tongue, and returning on the otiicr side and through the
sphincter aiii in precisely the same way as before. Now
the "pui'se-string" should be tied, and it will be eeon
that in Joiug this the posterior vaginal wall is drawn
downwards, while the two ends of the sphincter ani are
raised up to the centre.
Three silver sutures are now passed as in any ordinary
perineorrhaphy (Fig. 4). The lowest one catches the
reatored Hphinoter ani and takes most of the strain off the
" purso-etring." The upper one traiisfixcB the tougoc
Y, and the third is placed between.
When tht'se are closed the operation ie completed.
The pL'rinenl btitches include a quarter inch of skin at
either side, and t